primary care database: Topics by Science.gov

Sample records for primary care database

Integrated Primary Care Information Database (IPCI)

Cancer.gov

The Integrated Primary Care Information Database is a longitudinal observational database that was created specifically for pharmacoepidemiological and pharmacoeconomic studies, inlcuding data from computer-based patient records supplied voluntarily by general practitioners.
Improving Care And Research Electronic Data Trust Antwerp (iCAREdata): a research database of linked data on out-of-hours primary care.

PubMed

Colliers, Annelies; Bartholomeeusen, Stefaan; Remmen, Roy; Coenen, Samuel; Michiels, Barbara; Bastiaens, Hilde; Van Royen, Paul; Verhoeven, Veronique; Holmgren, Philip; De Ruyck, Bernard; Philips, Hilde

2016-05-04

Primary out-of-hours care is developing throughout Europe. High-quality databases with linked data from primary health services can help to improve research and future health services. In 2014, a central clinical research database infrastructure was established (iCAREdata: Improving Care And Research Electronic Data Trust Antwerp, www.icaredata.eu ) for primary and interdisciplinary health care at the University of Antwerp, linking data from General Practice Cooperatives, Emergency Departments and Pharmacies during out-of-hours care. Medical data are pseudonymised using the services of a Trusted Third Party, which encodes private information about patients and physicians before data is sent to iCAREdata. iCAREdata provides many new research opportunities in the fields of clinical epidemiology, health care management and quality of care. A key aspect will be to ensure the quality of data registration by all health care providers. This article describes the establishment of a research database and the possibilities of linking data from different primary out-of-hours care providers, with the potential to help to improve research and the quality of health care services.
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.
Beliefs, Knowledge, Implementation, and Integration of Evidence-Based Practice Among Primary Health Care Providers: Protocol for a Scoping Review.

PubMed

Pereira, Filipa; Salvi, Mireille; Verloo, Henk

2017-08-01

The adoption of evidence-based practice (EBP) is promoted because it is widely recognized for improving the quality and safety of health care for patients, and reducing avoidable costs. Providers of primary care face numerous challenges to ensuring the effectiveness of their daily practices. Primary health care is defined as: the entry level into a health care services system, providing a first point of contact for all new needs and problems; patient-focused (not disease-oriented) care over time; care for all but the most uncommon or unusual conditions; and coordination or integration of care, regardless of where or by whom that care is delivered. Primary health care is the principal means by which to approach the main goal of any health care services system: optimization of health status. This review aims to scope publications examining beliefs, knowledge, implementation, and integration of EBPs among primary health care providers (HCPs). We will conduct a systematic scoping review of published articles in the following electronic databases, from their start dates until March 31, 2017: Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed (from 1946), Embase (from 1947), Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1937), the Cochrane Central Register of Controlled Trials (CENTRAL; from 1992), PsycINFO (from 1806), Web of Science (from 1900), Joanna Briggs Institute (JBI) database (from 1998), Database of Abstracts of Reviews of Effects (DARE; from 1996), Trip medical database (from 1997), and relevant professional scientific journals (from their start dates). We will use the predefined search terms of, "evidence-based practice" and, "primary health care" combined with other terms, such as, "beliefs", "knowledge", "implementation", and "integration". We will also conduct a hand search of the bibliographies of all relevant articles and a search for unpublished studies using Google Scholar, ProQuest, Mednar, and WorldCat. We will consider publications in English, French, Spanish, and Portuguese. The electronic database searches were completed in April 2017. Retrieved articles are currently being screened, and the entire study is expected to be completed by November 2017. This systematic scoping review will provide a greater understanding of the beliefs, knowledge, implementation, and integration of EBPs among primary HCPs. The findings will inform clinical practice and help to draw a global picture of the EBP research topics that are relevant to primary care providers. ©Filipa Pereira, Mireille Salvi, Henk Verloo. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 01.08.2017.
Development and implementation of a psychotherapy tracking database in primary care.

PubMed

Craner, Julia R; Sawchuk, Craig N; Mack, John D; LeRoy, Michelle A

2017-06-01

Although there is a rapid increase in the integration of behavioral health services in primary care, few studies have evaluated the effectiveness of these services in real-world clinical settings, in part due to the difficulty of translating traditional mental health research designs to this setting. Accordingly, innovative approaches are needed to fit the unique challenges of conducting research in primary care. The development and implementation of one such approach is described in this article. A continuously populating database for psychotherapy services was implemented across 5 primary care clinics in a large health system to assess several levels of patient care, including service utilization, symptomatic outcomes, and session-by-session use of psychotherapy principles by providers. Each phase of implementation revealed challenges, including clinician time, dissemination to clinics with different resources, and fidelity of data collection strategy across providers, as well as benefits, including the generation of useful data to inform clinical care, program development, and empirical research. The feasible and sustainable implementation of data collection for routine clinical practice in primary care has the potential to fuel the evidence base around integrated care. The current project describes the development of an innovative approach that, with further empirical study and refinement, could enable health care professionals and systems to understand their population and clinical process in a way that addresses essential gaps in the integrated care literature. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
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.
Teleform scannable data entry: an efficient method to update a community-based medical record? Community care coordination network Database Group.

PubMed Central

Guerette, P.; Robinson, B.; Moran, W. P.; Messick, C.; Wright, M.; Wofford, J.; Velez, R.

1995-01-01

Community-based multi-disciplinary care of chronically ill individuals frequently requires the efforts of several agencies and organizations. The Community Care Coordination Network (CCCN) is an effort to establish a community-based clinical database and electronic communication system to facilitate the exchange of pertinent patient data among primary care, community-based and hospital-based providers. In developing a primary care based electronic record, a method is needed to update records from the field or remote sites and agencies and yet maintain data quality. Scannable data entry with fixed fields, optical character recognition and verification was compared to traditional keyboard data entry to determine the relative efficiency of each method in updating the CCCN database. PMID:8563414
[Quality Indicators of Primary Health Care Facilities in Austria].

PubMed

Semlitsch, Thomas; Abuzahra, Muna; Stigler, Florian; Jeitler, Klaus; Posch, Nicole; Siebenhofer, Andrea

2017-07-11

Background The strengthening of primary health care is one major goal of the current national health reform in Austria. In this context, a new interdisciplinary concept was developed in 2014 that defines structures and requirements for future primary health care facilities. Objective The aim of this project was the development of quality indicators for the evaluation of the scheduled primary health care facilities in Austria, which are in accordance with the new Austrian concept. Methods We used the RAND/NPCRDC method for the development and selection of the quality indicators. We conducted systematic literature searches for existing measures in international databases for quality indicators as well as in bibliographic databases. All retrieved measures were evaluated and rated by an expert panel in a 2-step process regarding relevance and feasibility. Results Overall, the literature searches yielded 281 potentially relevant quality indicators, which were summarized to 65 different quality measures for primary health care. Out of these, the panel rated and accepted 30 measures as relevant and feasible for use in Austria. Five of these indicators were structure measures, 14 were process measures and the remaining 11 were outcome measures. Based on the Austrian primary health care concept, the ﬁnal set of quality indicators was grouped in the 5 following domains: Access to primary health care (5), quality of care (15), continuity of care (5), coordination of care (4), and safety (1). Conclusion This set of quality measures largely covers the four defined functions of primary health care. It enables standardized evaluation of primary health care facilities in Austria regarding the implementation of the Austrian primary health care concept as well as improvement in healthcare of the population. © Georg Thieme Verlag KG Stuttgart · New York.
Backdating of events in electronic primary health care data: should one censor at the date of last data collection.

PubMed

Sammon, Cormac J; Petersen, Irene

2016-04-01

Studies using primary care databases often censor follow-up at the date data are last collected from clinical computer systems (last collection date (LCD)). We explored whether this results in the selective exclusion of events entered in the electronic health records after their date of occurrence, that is, backdated events. We used data from The Health Improvement Network (THIN). Using two versions of the database, we identified events that were entered into a later (THIN14) but not an earlier version of the database (THIN13) and investigated how the number of entries changed as a function of time since LCD. Times between events and the dates they were recorded were plotted as a function of time since the LCD in an effort to determine appropriate points at which to censor follow-up. There were 356 million eligible events in THIN14 and 355 million eligible events in THIN13. When comparing the two data sets, the proportion of missing events in THIN13 was highest in the month prior to the LCD (9.6%), decreasing to 5.2% at 6 months and 3.4% at 12 months. The proportion of missing events was largest for events typically diagnosed in secondary care such as neoplasms (28% in the month prior to LCD) and negligible for events typically diagnosed in primary care such as respiratory events (2% in the month prior to LCD). Studies using primary care databases, particularly those investigating events typically diagnosed outside primary care, should censor follow-up prior to the LCD to avoid underestimation of event rates. Copyright © 2016 John Wiley & Sons, Ltd.
Creation of the First French Database in Primary Care Using the ICPC2: Feasibility Study.

PubMed

Lacroix-Hugues, V; Darmon, D; Pradier, C; Staccini, P

2017-01-01

The objective of our study was to assess the feasibility of gathering data stored in primary care Electronic Health records (EHRs) in order to create a research database (PRIMEGE PACA project). The software for EHR models of two office and patient data management systems were analyzed; anonymized data was extracted and imported into a MySQL database. An ETL procedure to code text in ICPC2 codes was implemented. Eleven general practitioners (GPs) were enrolled as "data producers" and data were extracted from 2012 to 2015. In this paper, we explain the ways to make this process feasible as well as illustrate its utility for estimating epidemiological indicators and professional practice assessments. Other software is currently being analyzed for integration and expansion of this panel of GPs. This experimentation is recognized as a robust framework and is considered to be the technical foundation of the first regional observatory of primary care data.
Teaching Evidence-Based Medicine in the Era of Point-of-Care Databases: The Case of the Giant Bladder Stone.

PubMed

Kash, Melissa J

2016-01-01

In an era where physicians rely on point-of-care databases that provide filtered, pre-appraised, and quickly accessible clinical information by smartphone applications, it is difficult to teach medical students the importance of knowing not only when it is appropriate to search the primary medical literature but also how to do it. This column will describe how librarians at an academic health sciences library use an unusual clinical case to make demonstrations of searching primary medical literature real and meaningful to medical students, and to illustrate vividly the importance of knowing what to do when the answer to a clinical question cannot be found in a point-of-care database.
Spatial distribution of clinical computer systems in primary care in England in 2016 and implications for primary care electronic medical record databases: a cross-sectional population study.

PubMed

Kontopantelis, Evangelos; Stevens, Richard John; Helms, Peter J; Edwards, Duncan; Doran, Tim; Ashcroft, Darren M

2018-02-28

UK primary care databases (PCDs) are used by researchers worldwide to inform clinical practice. These databases have been primarily tied to single clinical computer systems, but little is known about the adoption of these systems by primary care practices or their geographical representativeness. We explore the spatial distribution of clinical computing systems and discuss the implications for the longevity and regional representativeness of these resources. Cross-sectional study. English primary care clinical computer systems. 7526 general practices in August 2016. Spatial mapping of family practices in England in 2016 by clinical computer system at two geographical levels, the lower Clinical Commissioning Group (CCG, 209 units) and the higher National Health Service regions (14 units). Data for practices included numbers of doctors, nurses and patients, and area deprivation. Of 7526 practices, Egton Medical Information Systems (EMIS) was used in 4199 (56%), SystmOne in 2552 (34%) and Vision in 636 (9%). Great regional variability was observed for all systems, with EMIS having a stronger presence in the West of England, London and the South; SystmOne in the East and some regions in the South; and Vision in London, the South, Greater Manchester and Birmingham. PCDs based on single clinical computer systems are geographically clustered in England. For example, Clinical Practice Research Datalink and The Health Improvement Network, the most popular primary care databases in terms of research outputs, are based on the Vision clinical computer system, used by <10% of practices and heavily concentrated in three major conurbations and the South. Researchers need to be aware of the analytical challenges posed by clustering, and barriers to accessing alternative PCDs need to be removed. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
A practice-based information system for multi-disciplinary care of chronically ill patients: what information do we need? The Community Care Coordination Network Database Group.

PubMed Central

Moran, W. P.; Messick, C.; Guerette, P.; Anderson, R.; Bradham, D.; Wofford, J. L.; Velez, R.

1994-01-01

Primary care physicians provide longitudinal care for chronically ill individuals in concert with many other community-based disciplines. The care management of these individuals requires data not traditionally collected during the care of well, or acutely ill individuals. These data not only concern the patient, in the form of patient functional status, mental status and affect, but also pertain to the caregiver, home environment, and the formal community health and social service system. The goal of the Community Care Coordination Network is to build a primary care-based information system to share patient data and communicate patient related information among the community-based multi-disciplinary teams. One objective of the Community Care Coordination Network is to create a Community Care Database for chronically ill individuals by identifying those data elements necessary for efficient multi-disciplinary care. PMID:7949995
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.
Identification of major cardiovascular events in patients with diabetes using primary care data.

PubMed

Pouwels, Koen Bernardus; Voorham, Jaco; Hak, Eelko; Denig, Petra

2016-04-02

Routine primary care data are increasingly being used for evaluation and research purposes but there are concerns about the completeness and accuracy of diagnoses and events captured in such databases. We evaluated how well patients with major cardiovascular disease (CVD) can be identified using primary care morbidity data and drug prescriptions. The study was conducted using data from 17,230 diabetes patients of the GIANTT database and Dutch Hospital Data register. To estimate the accuracy of the different measures, we analyzed the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) relative to hospitalizations and/or records with a diagnosis indicating major CVD, including ischaemic heart diseases and cerebrovascular events. Using primary care morbidity data, 43% of major CVD hospitalizations could be identified. Adding drug prescriptions to the search increased the sensitivity up to 94%. A proxy of at least one prescription of either a platelet aggregation inhibitor, vitamin k antagonist or nitrate could identify 85% of patients with a history of major CVD recorded in primary care, with an NPV of 97%. Using the same proxy, 57% of incident major CVD recorded in primary or hospital care could be identified, with an NPV of 99%. A substantial proportion of major CVD hospitalizations was not recorded in primary care morbidity data. Drug prescriptions can be used in addition to diagnosis codes to identify more patients with major CVD, and also to identify patients without a history of major CVD.
Challenges and Strategies in Providing Home Based Primary Care for Refugees in the US.

PubMed

Febles, C; Nies, M A; Fanning, K; Tavernier, S S

2017-12-01

The recent crisis in the Middle East has prompted the exodus of millions of refugees from the region who are at present seeking shelter across Europe and in the United States. Among the most immediate needs of refugees upon arrival in a host country is health care, and it is one of the most sustained interactions they experience. Home visits are a common form of primary care for refugees. The authors review the literature to identify themes related to challenges and strategies for providing home based primary care to refugees. The literature review was performed by searching cross-disciplinary databases utilizing Onesearch, but focusing primarily on results produced through CINAHL, EBSCOHOST, and Pub Med databases. To maximize the number of studies included, there was no time frame placed upon publication dates of articles within the search. A total of 55 articles were included in this paper.
From patient care to research: a validation study examining the factors contributing to data quality in a primary care electronic medical record database.

PubMed

Coleman, Nathan; Halas, Gayle; Peeler, William; Casaclang, Natalie; Williamson, Tyler; Katz, Alan

2015-02-05

Electronic Medical Records (EMRs) are increasingly used in the provision of primary care and have been compiled into databases which can be utilized for surveillance, research and informing practice. The primary purpose of these records is for the provision of individual patient care; validation and examination of underlying limitations is crucial for use for research and data quality improvement. This study examines and describes the validity of chronic disease case definition algorithms and factors affecting data quality in a primary care EMR database. A retrospective chart audit of an age stratified random sample was used to validate and examine diagnostic algorithms applied to EMR data from the Manitoba Primary Care Research Network (MaPCReN), part of the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). The presence of diabetes, hypertension, depression, osteoarthritis and chronic obstructive pulmonary disease (COPD) was determined by review of the medical record and compared to algorithm identified cases to identify discrepancies and describe the underlying contributing factors. The algorithm for diabetes had high sensitivity, specificity and positive predictive value (PPV) with all scores being over 90%. Specificities of the algorithms were greater than 90% for all conditions except for hypertension at 79.2%. The largest deficits in algorithm performance included poor PPV for COPD at 36.7% and limited sensitivity for COPD, depression and osteoarthritis at 72.0%, 73.3% and 63.2% respectively. Main sources of discrepancy included missing coding, alternative coding, inappropriate diagnosis detection based on medications used for alternate indications, inappropriate exclusion due to comorbidity and loss of data. Comparison to medical chart review shows that at MaPCReN the CPCSSN case finding algorithms are valid with a few limitations. This study provides the basis for the validated data to be utilized for research and informs users of its limitations. Analysis of underlying discrepancies provides the ability to improve algorithm performance and facilitate improved data quality.
Primary care teams in Ireland: a qualitative mapping review of Irish grey and published literature.

PubMed

O'Sullivan, M; Cullen, W; MacFarlane, A

2015-03-01

The Irish government published its primary care strategy, Primary Care: A New Direction in 2001. Progress with the implementation of Primary care teams is modest. The aim of this paper is to map the Irish grey literature and peer-reviewed publications to determine what research has been carried out in relation to primary care teams, the reform process and interdisciplinary working in primary care in Ireland. This scoping review employed three methods: a review of Web of Science, Medline and Embase databases, an email survey of researchers across academic institutions, the HSE and independent researchers and a review of Lenus and the Health Well repository. N = 123 outputs were identified. N = 14 were selected for inclusion. A thematic analysis was undertaken. Common themes identified were resources, GP participation, leadership, clarity regarding roles in primary care teams, skills and knowledge for primary care team working, communication and community. There is evidence of significant problems that disrupt team formation and functioning that warrants more comprehensive research.
Validating diagnostic information on the Minimum Data Set in Ontario Hospital-based long-term care.

PubMed

Wodchis, Walter P; Naglie, Gary; Teare, Gary F

2008-08-01

Over 20 countries currently use the Minimum Data Set Resident Assessment Instrument (MDS) in long-term care settings for care planning, policy, and research purposes. A full assessment of the quality of the diagnostic information recorded on the MDS is lacking. The primary goal of this study was to examine the quality of diagnostic coding on the MDS. Subjects for this study were admitted to Ontario Complex Continuing Care Hospitals (CCC) directly from acute hospitals between April 1, 1997 and March 31, 2005 (n = 80,664). Encrypted unique identifiers, common across acute and CCC administrative databases, were used to link administrative records for patients in the sample. After linkage, each resident had 2 sources of diagnostic information: the acute discharge abstract database and the MDS. Using the discharge abstract database as the reference standard, we calculated the sensitivity for each of 43 MDS diagnoses. Compared with primary diagnoses coded in acute care abstracts, 12 of 43 MDS diagnoses attained a sensitivity of at least 0.80, including 7 of the 10 diagnoses with the highest prevalence as an acute care primary diagnosis before CCC admission. Although the sensitivity was high for many of the most prevalent conditions, important diagnostic information is missed increasing the potential for suboptimal clinical care. Emphasis needs to be put on improving information flow across care settings during patient transitions. Researchers should exercise caution when using MDS diagnoses to identify patient populations, particularly those shown to have low sensitivity in this study.
Narrative review of provider behavior in primary care behavioral health: How process data can inform quality improvement.

PubMed

Beehler, Gregory P; Lilienthal, Kaitlin R; Possemato, Kyle; Johnson, Emily M; King, Paul R; Shepardson, Robyn L; Vair, Christina L; Reyner, Jacqueline; Funderburk, Jennifer S; Maisto, Stephen A; Wray, Laura O

2017-09-01

Primary care behavioral health (PCBH) is a population-based approach to delivering mental and behavioral health care in the primary care setting. Implementation of the PCBH model varies across practice settings, which can impact how PCBH providers deliver services to patients and in turn may predict a variety of important outcomes. This article aims to characterize PCBH provider engagement in key processes of integrated care as demonstrated in results from empirical studies of real-world clinical practice. For this narrative review of published studies on PCBH provider engagement in processes of care, PubMed and PsycINFO databases were searched from January 1990 through May 2016 to identify relevant articles. Provider adherence to the brief, time-limited treatment model appears suboptimal. Common mental health conditions, such as depression, were often the primary focus of provider attention, with less consistent emphasis on behavioral medicine concerns. Whereas providers regularly conducted qualitative functional assessments with patients, routine use of standardized measures was low. Engagement in interprofessional collaboration with the primary care team was also low, but engagement in behaviors that fostered therapeutic relationships was high. This review identified several strengths and weaknesses of typical PCBH provider practices. Results are discussed in relation to their value as areas for future quality improvement initiatives that can improve PCBH service delivery and, ultimately, patient outcomes. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

The strength of primary care in Europe: an international comparative study.

PubMed

Kringos, Dionne; Boerma, Wienke; Bourgueil, Yann; Cartier, Thomas; Dedeu, Toni; Hasvold, Toralf; Hutchinson, Allen; Lember, Margus; Oleszczyk, Marek; Rotar Pavlic, Danica; Svab, Igor; Tedeschi, Paolo; Wilm, Stefan; Wilson, Andrew; Windak, Adam; Van der Zee, Jouke; Groenewegen, Peter

2013-11-01

A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking. Evaluation of strength of primary care in Europe. International comparative cross-sectional study performed in 2009-2010, involving 27 EU member states, plus Iceland, Norway, Switzerland, and Turkey. Outcome measures covered three dimensions of primary care structure: primary care governance, economic conditions of primary care, and primary care workforce development; and four dimensions of primary care service-delivery process: accessibility, comprehensiveness, continuity, and coordination of primary care. The primary care dimensions were operationalised by a total of 77 indicators for which data were collected in 31 countries. Data sources included national and international literature, governmental publications, statistical databases, and experts' consultations. Countries with relatively strong primary care are Belgium, Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, Spain, and the UK. Countries either have many primary care policies and regulations in place, combined with good financial coverage and resources, and adequate primary care workforce conditions, or have consistently only few of these primary care structures in place. There is no correlation between the access, continuity, coordination, and comprehensiveness of primary care of countries. Variation is shown in the strength of primary care across Europe, indicating a discrepancy in the responsibility given to primary care in national and international policy initiatives and the needed investments in primary care to solve, for example, future shortages of workforce. Countries are consistent in their primary care focus on all important structure dimensions. Countries need to improve their primary care information infrastructure to facilitate primary care performance management.
Measuring Quality of Healthcare Outcomes in Type 2 Diabetes from Routine Data: a Seven-nation Survey Conducted by the IMIA Primary Health Care Working Group.

PubMed

Hinton, W; Liyanage, H; McGovern, A; Liaw, S-T; Kuziemsky, C; Munro, N; de Lusignan, S

2017-08-01

Background: The Institute of Medicine framework defines six dimensions of quality for healthcare systems: (1) safety, (2) effectiveness, (3) patient centeredness, (4) timeliness of care, (5) efficiency, and (6) equity. Large health datasets provide an opportunity to assess quality in these areas. Objective: To perform an international comparison of the measurability of the delivery of these aims, in people with type 2 diabetes mellitus (T2DM) from large datasets. Method: We conducted a survey to assess healthcare outcomes data quality of existing databases and disseminated this through professional networks. We examined the data sources used to collect the data, frequency of data uploads, and data types used for identifying people with T2DM. We compared data completeness across the six areas of healthcare quality, using selected measures pertinent to T2DM management. Results: We received 14 responses from seven countries (Australia, Canada, Italy, the Netherlands, Norway, Portugal, Turkey and the UK). Most databases reported frequent data uploads and would be capable of near real time analysis of healthcare quality.The majority of recorded data related to safety (particularly medication adverse events) and treatment efficacy (glycaemic control and microvascular disease). Data potentially measuring equity was less well recorded. Recording levels were lowest for patient-centred care, timeliness of care, and system efficiency, with the majority of databases containing no data in these areas. Databases using primary care sources had higher data quality across all areas measured. Conclusion: Data quality could be improved particularly in the areas of patient-centred care, timeliness, and efficiency. Primary care derived datasets may be most suited to healthcare quality assessment. Georg Thieme Verlag KG Stuttgart.
[The 'Beijing clinical database' on severe acute respiratory syndrome patients: its design, process, quality control and evaluation].

PubMed

2004-04-01

To develop a large database on clinical presentation, treatment and prognosis of all clinical diagnosed severe acute respiratory syndrome (SARS) cases in Beijing during the 2003 "crisis", in order to conduct further clinical studies. The database was designed by specialists, under the organization of the Beijing Commanding Center for SARS Treatment and Cure, including 686 data items in six sub-databases: primary medical-care seeking, vital signs, common symptoms and signs, treatment, laboratory and auxiliary test, and cost. All hospitals having received SARS inpatients were involved in the project. Clinical data was transferred and coded by trained doctors and data entry was carried out by trained nurses, according to a uniformed protocol. A series of procedures had been taken before the database was finally established which included programmed logic checking, digit-by-digit check on 5% random sample, data linkage for transferred cases, coding of characterized information, database structure standardization, case reviewe by computer program according to SARS Clinical Diagnosis Criteria issued by the Ministry of Health, and exclusion of unqualified patients. The database involved 2148 probable SARS cases in accordant with the clinical diagnosis criteria, including 1291 with complete records. All cases and record-complete cases showed an almost identical distribution in sex, age, occupation, residence areas and time of onset. The completion rate of data was not significantly different between the two groups except for some items on primary medical-care seeking. Specifically, the data completion rate was 73% - 100% in primary medical-care seeking, 90% in common symptoms and signs, 100% for treatment, 98% for temperature, 90% for pulse, 100% for outcomes and 98% for costs in hospital. The number of cases collected in the Beijing Clinical Database of SARS Patients was fairly complete. Cases with complete records showed that they could serve as excellent representatives of all cases. The completeness of data was quite satisfactory with primary clinical items which allowed for further clinical studies.
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.
Ethical quandaries in caring for primary-care patients with chronic pain.

PubMed

Robinson, Patricia J; Rickard, Julie A

2013-03-01

In the past decade, more and more behavioral health providers have begun consultation practices in primary-care settings. Their availability makes multidisciplinary care a reality and the possibility of improved outcomes for patients with chronic pain more feasible. However, behavioral health providers encounter new ethical quandaries in providing services to patients with chronic pain and to the primary-care providers who plan their treatment. This article presents two cases to illustrate the questions that arise in delivery of primary-care behavioral health services to patients with chronic pain. Relevant professional ethical guidelines for psychologists, social workers, and physicians are examined and recommendations for addressing the gaps in extant guides are offered. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Transtheoretical Model-Based Dietary Interventions in Primary Care: A Review of the Evidence in Diabetes

ERIC Educational Resources Information Center

Salmela, Sanna; Poskiparta, Marita; Kasila, Kirsti; Vahasarja, Kati; Vanhala, Mauno

2009-01-01

The objective of this study was to review the evidence concerning stage-based dietary interventions in primary care among persons with diabetes or an elevated diabetes risk. Search strategies were electronic databases and manual search. Selection criteria were randomized controlled studies with stage-based dietary intervention, conducted in…
[Prevalence of chronic fatigue syndrome in 4 family practices in Leiden].

PubMed

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

1997-08-02

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

PubMed

Janamian, Tina; Upham, Susan J; Crossland, Lisa; Jackson, Claire L

2016-04-18

To conduct a systematic review of the literature to identify existing online primary care quality improvement tools and resources to support organisational improvement related to the seven elements in the Primary Care Practice Improvement Tool (PC-PIT), with the identified tools and resources to progress to a Delphi study for further assessment of relevance and utility. Systematic review of the international published and grey literature. CINAHL, Embase and PubMed databases were searched in March 2014 for articles published between January 2004 and December 2013. GreyNet International and other relevant websites and repositories were also searched in March-April 2014 for documents dated between 1992 and 2012. All citations were imported into a bibliographic database. Published and unpublished tools and resources were included in the review if they were in English, related to primary care quality improvement and addressed any of the seven PC-PIT elements of a high-performing practice. Tools and resources that met the eligibility criteria were then evaluated for their accessibility, relevance, utility and comprehensiveness using a four-criteria appraisal framework. We used a data extraction template to systematically extract information from eligible tools and resources. A content analysis approach was used to explore the tools and resources and collate relevant information: name of the tool or resource, year and country of development, author, name of the organisation that provided access and its URL, accessibility information or problems, overview of each tool or resource and the quality improvement element(s) it addresses. If available, a copy of the tool or resource was downloaded into the bibliographic database, along with supporting evidence (published or unpublished) on its use in primary care. This systematic review identified 53 tools and resources that can potentially be provided as part of a suite of tools and resources to support primary care practices in improving the quality of their practice, to achieve improved health outcomes.
Health information technology in primary health care in developing countries: a literature review.

PubMed Central

Tomasi, Elaine; Facchini, Luiz Augusto; Maia, Maria de Fatima Santos

2004-01-01

This paper explores the debate and initiatives concerning the use of information technology (IT) in primary health care in developing countries. The literature from 1992-2002 was identified from searches of the MEDLINE, Latin American and Caribbean Health Science Literature Database (LILACS), Cochrane Library and Web of Science databases. The search identified 884 references, 350 of which were classified according to the scheme described by the Pan American Health Organization (PAHO). For the analysis of advantages, problems and perspectives of IT applications and systems, 52 articles were selected according to their potential contribution to the primary health-care processes in non-developed countries. These included: 10 on electronic patient registries (EPR), 22 on process and programmatic action evaluation and management systems (PPAEM) and 20 on clinical decision-support systems (CDS). The main advantages, limitations and perspectives are discussed. PMID:15640923
The Melbourne East Monash General Practice Database (MAGNET): Using data from computerised medical records to create a platform for primary care and health services research.

PubMed

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

2016-07-04

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

PubMed

Choi, J A; Sullivan, J; Pankaskie, M; Brufsky, J

1999-01-01

To evaluate prescription drug information contained in six consumer drug information databases available on CD-ROM, and to make health care professionals aware of the information provided, so that they may appropriately recommend these databases for use by their patients. Observational study of six consumer drug information databases: The Corner Drug Store, Home Medical Advisor, Mayo Clinic Family Pharmacist, Medical Drug Reference, Mosby's Medical Encyclopedia, and PharmAssist. Not applicable. Not applicable. Information on 20 frequently prescribed drugs was evaluated in each database. The databases were ranked using a point-scale system based on primary and secondary assessment criteria. For the primary assessment, 20 categories of information based on those included in the 1998 edition of the USP DI Volume II, Advice for the Patient: Drug Information in Lay Language were evaluated for each of the 20 drugs, and each database could earn up to 400 points (for example, 1 point was awarded if the database mentioned a drug's mechanism of action). For the secondary assessment, the inclusion of 8 additional features that could enhance the utility of the databases was evaluated (for example, 1 point was awarded if the database contained a picture of the drug), and each database could earn up to 8 points. The results of the primary and secondary assessments, listed in order of highest to lowest number of points earned, are as follows: Primary assessment--Mayo Clinic Family Pharmacist (379), Medical Drug Reference (251), PharmAssist (176), Home Medical Advisor (113.5), The Corner Drug Store (98), and Mosby's Medical Encyclopedia (18.5); secondary assessment--The Mayo Clinic Family Pharmacist (8), The Corner Drug Store (5), Mosby's Medical Encyclopedia (5), Home Medical Advisor (4), Medical Drug Reference (4), and PharmAssist (3). The Mayo Clinic Family Pharmacist was the most accurate and complete source of prescription drug information based on the USP DI Volume II and would be an appropriate database for health care professionals to recommend to patients.
The identification of incident cancers in UK primary care databases: a systematic review.

PubMed

Rañopa, Michael; Douglas, Ian; van Staa, Tjeerd; Smeeth, Liam; Klungel, Olaf; Reynolds, Robert; Bhaskaran, Krishnan

2015-01-01

UK primary care databases are frequently used in observational studies with cancer outcomes. We aimed to systematically review methods used by such studies to identify and validate incident cancers of the breast, colorectum, and prostate. Medline and Embase (1980-2013) were searched for UK primary care database studies with incident breast, colorectal, or prostate cancer outcomes. Data on the methods used for case ascertainment were extracted and summarised. Questionnaires were sent to corresponding authors to obtain details about case ascertainment. Eighty-four studies of breast (n = 51), colorectal (n = 54), and prostate cancer (n = 31) were identified; 30 examined >1 cancer type. Among the 84 studies, 57 defined cancers using only diagnosis codes, while 27 required further evidence such as chemotherapy. Few studies described methods used to create cancer code lists (n = 5); or made lists available directly (n = 5). Twenty-eight code lists were received on request from study authors. All included malignant neoplasm diagnosis codes, but there was considerable variation in the specific codes included which was not explained by coding dictionary changes. Code lists also varied in terms of other types of codes included, such as in-situ, cancer morphology, history of cancer, and secondary/suspected/borderline cancer codes. In UK primary care database studies, methods for identifying breast, colorectal, and prostate cancers were often unclear. Code lists were often unavailable, and where provided, we observed variation in the individual codes and types of codes included. Clearer reporting of methods and publication of code lists would improve transparency and reproducibility of studies. Copyright © 2014 John Wiley & Sons, Ltd.
Ascertainment of acute liver injury in two European primary care databases.

PubMed

Ruigómez, A; Brauer, R; Rodríguez, L A García; Huerta, C; Requena, G; Gil, M; de Abajo, Francisco; Downey, G; Bate, A; Tepie, M Feudjo; de Groot, M; Schlienger, R; Reynolds, R; Klungel, O

2014-10-01

The purpose of this study was to ascertain acute liver injury (ALI) in primary care databases using different computer algorithms. The aim of this investigation was to study and compare the incidence of ALI in different primary care databases and using different definitions of ALI. The Clinical Practice Research Datalink (CPRD) in UK and the Spanish "Base de datos para la Investigación Farmacoepidemiológica en Atención Primaria" (BIFAP) were used. Both are primary care databases from which we selected individuals of all ages registered between January 2004 and December 2009. We developed two case definitions of idiopathic ALI using computer algorithms: (i) restrictive definition (definite cases) and (ii) broad definition (definite and probable cases). Patients presenting prior liver conditions were excluded. Manual review of potential cases was performed to confirm diagnosis, in a sample in CPRD (21%) and all potential cases in BIFAP. Incidence rates of ALI by age, sex and calendar year were calculated. In BIFAP, all cases considered definite after manual review had been detected with the computer algorithm as potential cases, and none came from the non-cases group. The restrictive definition of ALI had a low sensitivity but a very high specificity (95% in BIFAP) and showed higher rates of agreement between computer search and manual review compared to the broad definition. Higher incidence rates of definite ALI in 2008 were observed in BIFAP (3.01 (95% confidence interval (CI) 2.13-4.25) per 100,000 person-years than CPRD (1.35 (95% CI 1.03-1.78)). This study shows that it is feasible to identify ALI cases if restrictive selection criteria are used and the possibility to review additional information to rule out differential diagnoses. Our results confirm that idiopathic ALI is a very rare disease in the general population. Finally, the construction of a standard definition with predefined criteria facilitates the timely comparison across databases.
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.
Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care

PubMed Central

Valentijn, Pim P.; Schepman, Sanneke M.; Opheij, Wilfrid; Bruijnzeels, Marc A.

2013-01-01

Introduction Primary care has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated care hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary care and integrated care, in order to understand the complexity of integrated care. Methods The search method involved a combination of electronic database searches, hand searches of reference lists (snowball method) and contacting researchers in the field. The process of synthesizing the literature was iterative, to relate the concepts of primary care and integrated care. First, we identified the general principles of primary care and integrated care. Second, we connected the dimensions of integrated care and the principles of primary care. Finally, to improve content validity we held several meetings with researchers in the field to develop and refine our conceptual framework. Results The conceptual framework combines the functions of primary care with the dimensions of integrated care. Person-focused and population-based care serve as guiding principles for achieving integration across the care continuum. Integration plays complementary roles on the micro (clinical integration), meso (professional and organisational integration) and macro (system integration) level. Functional and normative integration ensure connectivity between the levels. Discussion The presented conceptual framework is a first step to achieve a better understanding of the inter-relationships among the dimensions of integrated care from a primary care perspective. PMID:23687482
Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care.

PubMed

Valentijn, Pim P; Schepman, Sanneke M; Opheij, Wilfrid; Bruijnzeels, Marc A

2013-01-01

Primary care has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated care hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary care and integrated care, in order to understand the complexity of integrated care. The search method involved a combination of electronic database searches, hand searches of reference lists (snowball method) and contacting researchers in the field. The process of synthesizing the literature was iterative, to relate the concepts of primary care and integrated care. First, we identified the general principles of primary care and integrated care. Second, we connected the dimensions of integrated care and the principles of primary care. Finally, to improve content validity we held several meetings with researchers in the field to develop and refine our conceptual framework. The conceptual framework combines the functions of primary care with the dimensions of integrated care. Person-focused and population-based care serve as guiding principles for achieving integration across the care continuum. Integration plays complementary roles on the micro (clinical integration), meso (professional and organisational integration) and macro (system integration) level. Functional and normative integration ensure connectivity between the levels. The presented conceptual framework is a first step to achieve a better understanding of the inter-relationships among the dimensions of integrated care from a primary care perspective.
To self-disclose or not self-disclose? A systematic review of clinical self-disclosure in primary care.

PubMed

Arroll, Bruce; Allen, Emily-Charlotte Frances

2015-09-01

There is a debate in medicine about the value of self-disclosure by the physician as a communication tool. To review the empirical literature of self-disclosure in primary care. Systematic review of empirical literature relating to self-disclosure by primary care physicians (including US paediatricians) from seven electronic databases (MEDLINE(®), Scopus, PsycINFO, Embase, Social Sciences Citation Index, EBSCOhost, and Cochrane Central Register of Controlled Trials [CENTRAL]). Databases were searched for empirical studies on self-disclosure and primary care published from 1946 to 28 November 2014, as well as references from primary studies. The search was extended to include working papers, theses, and dissertations. Nine studies were identified, with response rates ranging from 34% to 100%, as well as several not reported. Self-disclosure occurred in 14-75% of consultations, the most from paediatricians. Self-disclosure had intended benefit; however, one standardised patient study found that 85% of self-disclosures were not useful as reported by the transcript coders. Conflicting data emerged on the self-disclosure outcome. This is the first systematic review of self-disclosure in primary care and medicine. Self-disclosure appears to be common and has the potential to be helpful when used judiciously. Few studies examined the impact on patients, and no studies considered the individual patient perspective nor the content which results in benefit or harm. No evidence was found of any training into how to deal with self-disclosure. © British Journal of General Practice 2015.
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.
Abstraction of the Relational Model from a Department of Veterans Affairs DHCP Database: Bridging Theory and Working Application

PubMed Central

Levy, C.; Beauchamp, C.

1996-01-01

This poster describes the methods used and working prototype that was developed from an abstraction of the relational model from the VA's hierarchical DHCP database. Overlaying the relational model on DHCP permits multiple user views of the physical data structure, enhances access to the database by providing a link to commercial (SQL based) software, and supports a conceptual managed care data model based on primary and longitudinal patient care. The goal of this work was to create a relational abstraction of the existing hierarchical database; to construct, using SQL data definition language, user views of the database which reflect the clinical conceptual view of DHCP, and to allow the user to work directly with the logical view of the data using GUI based commercial software of their choosing. The workstation is intended to serve as a platform from which a managed care information model could be implemented and evaluated.
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.

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.
Validity of registration of ICD codes and prescriptions in a research database in Swedish primary care: a cross-sectional study in Skaraborg primary care database

PubMed Central

2010-01-01

Background In recent years, several primary care databases recording information from computerized medical records have been established and used for quality assessment of medical care and research. However, to be useful for research purposes, the data generated routinely from every day practice require registration of high quality. In this study we aimed to investigate (i) the frequency and validity of ICD code and drug prescription registration in the new Skaraborg primary care database (SPCD) and (ii) to investigate the sources of variation in this registration. Methods SPCD contains anonymous electronic medical records (ProfDoc III) automatically retrieved from all 24 public health care centres (HCC) in Skaraborg, Sweden. The frequencies of ICD code registration for the selected diagnoses diabetes mellitus, hypertension and chronic cardiovascular disease and the relevant drug prescriptions in the time period between May 2002 and October 2003 were analysed. The validity of data registration in the SPCD was assessed in a random sample of 50 medical records from each HCC (n = 1200 records) using the medical record text as gold standard. The variance of ICD code registration was studied with multi-level logistic regression analysis and expressed as median odds ratio (MOR). Results For diabetes mellitus and hypertension ICD codes were registered in 80-90% of cases, while for congestive heart failure and ischemic heart disease ICD codes were registered more seldom (60-70%). Drug prescription registration was overall high (88%). A correlation between the frequency of ICD coded visits and the sensitivity of the ICD code registration was found for hypertension and congestive heart failure but not for diabetes or ischemic heart disease. The frequency of ICD code registration varied from 42 to 90% between HCCs, and the greatest variation was found at the physician level (MORPHYSICIAN = 4.2 and MORHCC = 2.3). Conclusions Since the frequency of ICD code registration varies between different diagnoses, each diagnosis must be separately validated. Improved frequency and quality of ICD code registration might be achieved by interventions directed towards the physicians where the greatest amount of variation was found. PMID:20416069
Validity of registration of ICD codes and prescriptions in a research database in Swedish primary care: a cross-sectional study in Skaraborg primary care database.

PubMed

Hjerpe, Per; Merlo, Juan; Ohlsson, Henrik; Bengtsson Boström, Kristina; Lindblad, Ulf

2010-04-23

In recent years, several primary care databases recording information from computerized medical records have been established and used for quality assessment of medical care and research. However, to be useful for research purposes, the data generated routinely from every day practice require registration of high quality. In this study we aimed to investigate (i) the frequency and validity of ICD code and drug prescription registration in the new Skaraborg primary care database (SPCD) and (ii) to investigate the sources of variation in this registration. SPCD contains anonymous electronic medical records (ProfDoc III) automatically retrieved from all 24 public health care centres (HCC) in Skaraborg, Sweden. The frequencies of ICD code registration for the selected diagnoses diabetes mellitus, hypertension and chronic cardiovascular disease and the relevant drug prescriptions in the time period between May 2002 and October 2003 were analysed. The validity of data registration in the SPCD was assessed in a random sample of 50 medical records from each HCC (n = 1200 records) using the medical record text as gold standard. The variance of ICD code registration was studied with multi-level logistic regression analysis and expressed as median odds ratio (MOR). For diabetes mellitus and hypertension ICD codes were registered in 80-90% of cases, while for congestive heart failure and ischemic heart disease ICD codes were registered more seldom (60-70%). Drug prescription registration was overall high (88%). A correlation between the frequency of ICD coded visits and the sensitivity of the ICD code registration was found for hypertension and congestive heart failure but not for diabetes or ischemic heart disease.The frequency of ICD code registration varied from 42 to 90% between HCCs, and the greatest variation was found at the physician level (MORPHYSICIAN = 4.2 and MORHCC = 2.3). Since the frequency of ICD code registration varies between different diagnoses, each diagnosis must be separately validated. Improved frequency and quality of ICD code registration might be achieved by interventions directed towards the physicians where the greatest amount of variation was found.
ADHD in school-aged youth: Management and special treatment considerations in the primary care setting.

PubMed

Weed, Elizabeth D

Attention-deficit/hyperactivity disorder is considered one of the most common neurodevelopmental disorders of childhood. Primary care providers are in the unique position of providing comprehensive care-routine care, well child visits, immunizations, and other healthcare needs-to a majority of children and adolescents with attention-deficit/hyperactivity disorder. As such, primary care providers are pivotal in the diagnosis, management, and treatment of this population. This article will address special treatment considerations to aid in the management of attention-deficit/hyperactivity disorder in the primary care setting, including substance use disorders and diversion, cardiac issues and stimulant medication, medication holidays and follow-up monitoring. The database of PubMed was searched using keywords that included attention-deficit/hyperactivity disorder, children, prevalence, medication holidays, safety, cardiovascular, cardiac, blood pressure, substance use, diversion, adverse drug reactions; inclusion dates were January 1, 2011 to September 30, 2015. © The Author(s) 2016.
[Primary Health Care in the coordination of health care networks: an integrative review].

PubMed

Rodrigues, Ludmila Barbosa Bandeira; Silva, Patricia Costa Dos Santos; Peruhype, Rarianne Carvalho; Palha, Pedro Fredemir; Popolin, Marcela Paschoal; Crispim, Juliane de Almeida; Pinto, Ione Carvalho; Monroe, Aline Aparecida; Arcêncio, Ricardo Alexandre

2014-02-01

Health systems organized in health care networks and coordinated by Primary Health Care can contribute to an improvement in clinical quality with a positive impact on health outcomes and user satisfaction (by improving access and resolubility) and a reduction in the costs of local health systems. Thus, the scope of this paper is to analyze the scientific output about the evidence, potential, challenges and prospects of Primary Health Care in the coordination of Health Care Networks. To achieve this, the integrative review method was selected covering the period between 2000 and 2011. The databases selected were Medline (Medical Literature Analysis and Retrieval System online), Lilacs (Latin American Literature in Health Sciences) and SciELO (Scientific Electronic Library Online). Eighteen articles fulfilled the selection criteria. It was seen that the potential impacts of primary care services supersede the inherent weaknesses. However, the results revealed the need for research with a higher level of classification of the scientific evidence about the role of Primary Healh Care in the coordination of Health Care Networks.
Attitudes to evidence-based medicine of primary care physicians in Asir region, Saudi Arabia.

PubMed

Khoja, T A; Al-Ansary, L A

2007-01-01

A questionnaire survey was made of primary health care physicians in Asir region, Saudi Arabia in 1999 to explore their awareness of and attitude towards evidence-based medicine. The 272 respondents welcomed the principles of evidence-based medicine. Awareness and use of extracting journals, review publications and databases was low. Pharmaceutical company sponsored journals were the most commonly read. Bibliographic databases could only be accessed by 13% of respondents and the Internet by only 6%. There was only partial understanding of technical terms used in evidence-based medicine. Absence of a local library and increased patient workload were seen by most respondents as the main obstacles to practising evidence-based medicine.
Use of a primary care database to determine trends in genital chlamydia testing, diagnostic episodes and management in UK general practice, 1990–2004

PubMed Central

Hughes, Gwenda; Williams, Tim; Simms, Ian; Mercer, Catherine; Fenton, Kevin; Cassell, Jackie

2007-01-01

Objective To determine the extent of testing, diagnostic episodes and management of genital Chlamydia trachomatis (CT) infection in UK primary care using a large primary care database. Methods The incidence of CT tests, diagnostic episodes, treatments and referrals was measured for all adult patients in the General Practice Research Database between 1990 and 2004. Results Rates of CT testing in those aged 12–64 years in 2004 increased to 1439/100 000 patient years (py) in women but only 74/100 000 py in men. Testing rates were highest among 20–24‐year‐old women (5.5% tested in 2004), followed by 25–34‐year‐old women (3.7% tested in 2004). 0.5% of registered 16–24‐year‐old women were diagnosed as having CT infection in 2004. Three‐quarters of patients with a recorded diagnosis of CT had had an appropriate prescription issued in 2004, a proportion that increased from 1990 along with a decrease in referrals to genitourinary medicine. In 2004, general practitioners treated 25.0% of all recorded diagnoses of CT in women and 5.1% of those in men. Conclusions Testing for and diagnostic episodes of CT in primary care have increased since 1990. Testing continues disproportionately to target women aged >24 years. Extremely low rates of testing in men, together with high positivity, demonstrate a missed opportunity for diagnosis of CT and contact tracing in general practice. PMID:17360731
The effect of care pathways for hip fractures: a systematic review.

PubMed

Leigheb, Fabrizio; Vanhaecht, Kris; Sermeus, Walter; Lodewijckx, Cathy; Deneckere, Svin; Boonen, Steven; Boto, Paulo Alexandre Faria; Mendes, Rita Veloso; Panella, Massimiliano

2012-07-01

We performed a systematic review for primary studies on care pathways (CPs) for hip fracture (HF). The online databases MEDLINE-PubMed, Ovid-EMBASE, CINAHL-EBSCO host, and The Cochrane Library (Cochrane Central Register of Clinical Trials, Health Technology Assessment Database, NHS Economic Evaluation Database) were searched. Two researchers reviewed the literature independently. Primary studies that met predefined inclusion criteria were assessed for their methodological quality. A total of 15 publications were included: 15 primary studies corresponding with 12 main investigations. Primary studies were evaluated for clinical outcomes, process outcomes, and economic outcomes. The studies assessed a wide range of outcome measures. While a number of divergent clinical outcomes were reported, most studies showed positive results of process management and health-services utilization. In terms of mortality, the results provided evidence for a positive impact of CPs on in-hospital mortality. Most studies also showed a significantly reduced risk of complications, including medical complications, wound infections, and pressure sores. Moreover, time-span process measures showed that an improvement in the organization of care was achieved through the use of CPs. Conflicting results were observed with regard to functional recovery and mobility between patients treated with CPs compared to usual care. Although our review suggests that CPs can have positive effects in patients with HF, the available evidence is insufficient for formal recommendations. There is a need for more research on CPs with selected process and outcome indicators, for in-hospital and postdischarge management of HF, with an emphasis on well-designed randomized trials.
Integrated primary care, the collaboration imperative inter-organizational cooperation in the integrated primary care field: a theoretical framework

PubMed Central

Valentijn, Pim P; Bruijnzeels, Marc A; de Leeuw, Rob J; Schrijvers, Guus J.P

2012-01-01

Purpose Capacity problems and political pressures have led to a rapid change in the organization of primary care from mono disciplinary small business to complex inter-organizational relationships. It is assumed that inter-organizational collaboration is the driving force to achieve integrated (primary) care. Despite the importance of collaboration and integration of services in primary care, there is no unambiguous definition for both concepts. The purpose of this study is to examine and link the conceptualisation and validation of the terms inter-organizational collaboration and integrated primary care using a theoretical framework. Theory The theoretical framework is based on the complex collaboration process of negotiation among multiple stakeholder groups in primary care. Methods A literature review of health sciences and business databases, and targeted grey literature sources. Based on the literature review we operationalized the constructs of inter-organizational collaboration and integrated primary care in a theoretical framework. The framework is being validated in an explorative study of 80 primary care projects in the Netherlands. Results and conclusions Integrated primary care is considered as a multidimensional construct based on a continuum of integration, extending from segregation to integration. The synthesis of the current theories and concepts of inter-organizational collaboration is insufficient to deal with the complexity of collaborative issues in primary care. One coherent and integrated theoretical framework was found that could make the complex collaboration process in primary care transparent. This study presented theoretical framework is a first step to understand the patterns of successful collaboration and integration in primary care services. These patterns can give insights in the organization forms needed to create a good working integrated (primary) care system that fits the local needs of a population. Preliminary data of the patterns of collaboration and integration will be presented.
Development of a validated algorithm for the diagnosis of paediatric asthma in electronic medical records

PubMed Central

Cave, Andrew J; Davey, Christina; Ahmadi, Elaheh; Drummond, Neil; Fuentes, Sonia; Kazemi-Bajestani, Seyyed Mohammad Reza; Sharpe, Heather; Taylor, Matt

2016-01-01

An accurate estimation of the prevalence of paediatric asthma in Alberta and elsewhere is hampered by uncertainty regarding disease definition and diagnosis. Electronic medical records (EMRs) provide a rich source of clinical data from primary-care practices that can be used in better understanding the occurrence of the disease. The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) database includes cleaned data extracted from the EMRs of primary-care practitioners. The purpose of the study was to develop and validate a case definition of asthma in children 1–17 who consult family physicians, in order to provide primary-care estimates of childhood asthma in Alberta as accurately as possible. The validation involved the comparison of the application of a theoretical algorithm (to identify patients with asthma) to a physician review of records included in the CPCSSN database (to confirm an accurate diagnosis). The comparison yielded 87.4% sensitivity, 98.6% specificity and a positive and negative predictive value of 91.2% and 97.9%, respectively, in the age group 1–17 years. The algorithm was also run for ages 3–17 and 6–17 years, and was found to have comparable statistical values. Overall, the case definition and algorithm yielded strong sensitivity and specificity metrics and was found valid for use in research in CPCSSN primary-care practices. The use of the validated asthma algorithm may improve insight into the prevalence, diagnosis, and management of paediatric asthma in Alberta and Canada. PMID:27882997
Development of a validated algorithm for the diagnosis of paediatric asthma in electronic medical records.

PubMed

Cave, Andrew J; Davey, Christina; Ahmadi, Elaheh; Drummond, Neil; Fuentes, Sonia; Kazemi-Bajestani, Seyyed Mohammad Reza; Sharpe, Heather; Taylor, Matt

2016-11-24

An accurate estimation of the prevalence of paediatric asthma in Alberta and elsewhere is hampered by uncertainty regarding disease definition and diagnosis. Electronic medical records (EMRs) provide a rich source of clinical data from primary-care practices that can be used in better understanding the occurrence of the disease. The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) database includes cleaned data extracted from the EMRs of primary-care practitioners. The purpose of the study was to develop and validate a case definition of asthma in children 1-17 who consult family physicians, in order to provide primary-care estimates of childhood asthma in Alberta as accurately as possible. The validation involved the comparison of the application of a theoretical algorithm (to identify patients with asthma) to a physician review of records included in the CPCSSN database (to confirm an accurate diagnosis). The comparison yielded 87.4% sensitivity, 98.6% specificity and a positive and negative predictive value of 91.2% and 97.9%, respectively, in the age group 1-17 years. The algorithm was also run for ages 3-17 and 6-17 years, and was found to have comparable statistical values. Overall, the case definition and algorithm yielded strong sensitivity and specificity metrics and was found valid for use in research in CPCSSN primary-care practices. The use of the validated asthma algorithm may improve insight into the prevalence, diagnosis, and management of paediatric asthma in Alberta and Canada.
Unrecognised bipolar disorder among UK primary care patients prescribed antidepressants: an observational study.

PubMed

Hughes, Tom; Cardno, Alastair; West, Robert; Marino-Francis, Federica; Featherstone, Imogen; Rolling, Keeley; Locker, Alice; McLintock, Kate; House, Allan

2016-02-01

Bipolar disorder is not uncommon, is associated with high disability and risk of suicide, often presents with depression, and can go unrecognised. To determine the prevalence of unrecognised bipolar disorder among those prescribed antidepressants for depressive or anxiety disorder in UK primary care; whether those with unrecognised bipolar disorder have more severe depression than those who do not; and the accuracy of a screening questionnaire for bipolar disorder, the Mood Disorder Questionnaire (MDQ), in this setting. Observational primary care study of patients on the lists of 21 general practices in West Yorkshire aged 16-40 years and prescribed antidepressant medication. Participants were recruited using primary care databases, interviewed using a diagnostic interview, and completed the screening questionnaire and rating scales of symptoms and quality of life. The prevalence of unrecognised bipolar disorder was 7.3%. Adjusting for differences between the sample and a national database gives a prevalence of 10.0%. Those with unrecognised bipolar disorder were younger and had greater lifetime depression. The predictive value of the MDQ was poor. Among people aged 16-40 years prescribed antidepressants in primary care for depression or anxiety, there is a substantial proportion with unrecognised bipolar disorder. When seeing patients with depression or anxiety disorder, particularly when they are young or not doing well, clinicians should review the life history for evidence of unrecognised bipolar disorder. Some clinicians might find the MDQ to be a useful supplement to non-standardised questioning. © British Journal of General Practice 2016.
Nursing Minimum Data Sets for documenting nutritional care for adults in primary healthcare: a scoping review.

PubMed

Håkonsen, Sasja Jul; Pedersen, Preben Ulrich; Bjerrum, Merete; Bygholm, Ann; Peters, Micah D J

2018-01-01

To identify all published nutritional screening instruments that have been validated in the adult population in primary healthcare settings and to report on their psychometric validity. Within health care, there is an urgent need for the systematic collection of nursing care data in order to make visible what nurses do and to facilitate comparison, quality assurance, management, research and funding of nursing care. To be effective, nursing records should accurately and comprehensively document all required information to support safe and high quality care of patients. However, this process of documentation has been criticized from many perspectives as being highly inadequate. A Nursing Minimum Data Set within the nutritional area in primary health care could therefore be beneficial in order to support nurses in their daily documentation and observation of patients. The review considered studies that included adults aged over 18 years of any gender, culture, diagnosis and ethnicity, as well as nutritional experts, patients and their relatives. The concepts of interest were: the nature and content of any nutritional screening tools validated (regardless of the type of validation) in the adult population in primary healthcare; and the views and opinions of eligible participants regarding the appropriateness of nutritional assessment were the concept of interest. Studies included must have been conducted in primary healthcare settings, both within home care and nursing home facilities. This scoping review used a two-step approach as a preliminary step to the subsequent development of a Nursing Minimum Data Set within the nutritional area in primary healthcare: i) a systematic literature search of existing nutritional screening tools validated in primary health care; and ii) a systematic literature search on nutritional experts opinions on the assessment of nutritional nursing care of adults in primary healthcare as well as the views of patients and their relatives. Multiple databases (PubMed, CINAHL, Embase, Scopus, Swemed+, MedNar, CDC, MEDION, Health Technology Assessment Database, TRIP database, NTIS, ProQuest Dissertations and Theses, Google Scholar, Current Contents) were searched from their inception to September 2016. The results from the studies were extracted using pre-developed extraction tools to all three questions, and have been presented narratively and by using figures to support the text. Twenty-nine nutritional screening tools that were validated within a primary care setting, and two documents on consensus statements regarding expert opinion were identified. No studies on the patients or relatives views were identified. The nutritional screening instruments have solely been validated in an over-55 population. Construct validity was the type of validation most frequently used in the validation process covering a total of 25 of the 29 tools. Two studies were identified in relation to the third review question. These two documents are both consensus statement documents developed by experts within the geriatric and nutritional care field. Overall, experts find it appropriate to: i) conduct a comprehensive geriatric assessment, ii) use a validated nutritional screening instrument, and iii) conduct a history and clinical diagnosis, physical examination and dietary assessment when assessing primarily the elderly's nutritional status in primary health care.
To self-disclose or not self-disclose? A systematic review of clinical self-disclosure in primary care

PubMed Central

Arroll, Bruce; Allen, Emily-Charlotte Frances

2015-01-01

Background There is a debate in medicine about the value of self-disclosure by the physician as a communication tool. Aim To review the empirical literature of self-disclosure in primary care. Design and setting Systematic review of empirical literature relating to self-disclosure by primary care physicians (including US paediatricians) from seven electronic databases (MEDLINE®, Scopus, PsycINFO, Embase, Social Sciences Citation Index, EBSCOhost, and Cochrane Central Register of Controlled Trials [CENTRAL]). Method Databases were searched for empirical studies on self-disclosure and primary care published from 1946 to 28 November 2014, as well as references from primary studies. The search was extended to include working papers, theses, and dissertations. Results Nine studies were identified, with response rates ranging from 34% to 100%, as well as several not reported. Self-disclosure occurred in 14–75% of consultations, the most from paediatricians. Self-disclosure had intended benefit; however, one standardised patient study found that 85% of self-disclosures were not useful as reported by the transcript coders. Conflicting data emerged on the self-disclosure outcome. Conclusion This is the first systematic review of self-disclosure in primary care and medicine. Self-disclosure appears to be common and has the potential to be helpful when used judiciously. Few studies examined the impact on patients, and no studies considered the individual patient perspective nor the content which results in benefit or harm. No evidence was found of any training into how to deal with self-disclosure. PMID:26324498
Which DSM validated tools for diagnosing depression are usable in primary care research? A systematic literature review.

PubMed

Nabbe, P; Le Reste, J Y; Guillou-Landreat, M; Munoz Perez, M A; Argyriadou, S; Claveria, A; Fernández San Martín, M I; Czachowski, S; Lingner, H; Lygidakis, C; Sowinska, A; Chiron, B; Derriennic, J; Le Prielec, A; Le Floch, B; Montier, T; Van Marwijk, H; Van Royen, P

2017-01-01

Depression occurs frequently in primary care. Its broad clinical variability makes it difficult to diagnose. This makes it essential that family practitioner (FP) researchers have validated tools to minimize bias in studies of everyday practice. Which tools validated against psychiatric examination, according to the major depression criteria of DSM-IV or 5, can be used for research purposes? An international FP team conducted a systematic review using the following databases: Pubmed, Cochrane and Embase, from 2000/01/01 to 2015/10/01. The three databases search identified 770 abstracts: 546 abstracts were analyzed after duplicates had been removed (224 duplicates); 50 of the validity studies were eligible and 4 studies were included. In 4 studies, the following tools were found: GDS-5, GDS-15, GDS-30, CESD-R, HADS, PSC-51 and HSCL-25. Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value were collected. The Youden index was calculated. Using efficiency data alone to compare these studies could be misleading. Additional reliability, reproducibility and ergonomic data will be essential for making comparisons. This study selected seven tools, usable in primary care research, for the diagnosis of depression. In order to define the best tools in terms of efficiency, reproducibility, reliability and ergonomics for research in primary care, and for care itself, further research will be essential. Copyright © 2016. Published by Elsevier Masson SAS.
Follow-up of cancer in primary care versus secondary care: systematic review

PubMed Central

Lewis, Ruth A; Neal, Richard D; Williams, Nefyn H; France, Barbara; Hendry, Maggie; Russell, Daphne; Hughes, Dyfrig A; Russell, Ian; Stuart, Nicholas SA; Weller, David; Wilkinson, Clare

2009-01-01

Background Cancer follow-up has traditionally been undertaken in secondary care, but there are increasing calls to deliver it in primary care. Aim To compare the effectiveness and cost-effectiveness of primary versus secondary care follow-up of cancer patients, determine the effectiveness of the integration of primary care in routine hospital follow-up, and evaluate the impact of patient-initiated follow-up on primary care. Design of study Systematic review. Setting Primary and secondary care settings. Method A search was carried out of 19 electronic databases, online trial registries, conference proceedings, and bibliographies of included studies. The review included comparative studies or economic evaluations of primary versus secondary care follow-up, hospital follow-up with formal primary care involvement versus conventional hospital follow-up, and hospital follow-up versus patient-initiated or minimal follow-up if the study reported the impact on primary care. Results There was no statistically significant difference for patient wellbeing, recurrence rate, survival, recurrence-related serious clinical events, diagnostic delay, or patient satisfaction. GP-led breast cancer follow-up was cheaper than hospital follow-up. Intensified primary health care resulted in increased home-care nurse contact, and improved discharge summary led to increased GP contact. Evaluation of patient-initiated or minimal follow-up found no statistically significant impact on the number of GP consultations or cancer-related referrals. Conclusion Weak evidence suggests that breast cancer follow-up in primary care is effective. Interventions improving communication between primary and secondary care could lead to greater GP involvement. Discontinuation of formal follow-up may not increase GP workload. However, the quality of the data in general was poor, and no firm conclusions can be reached. PMID:19566990
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
Burnout syndrome and its prevalence in primary care nursing: a systematic review and meta-analysis.

PubMed

Monsalve-Reyes, Carolina S; San Luis-Costas, Concepción; Gómez-Urquiza, Jose L; Albendín-García, Luis; Aguayo, Raimundo; Cañadas-De la Fuente, Guillermo A

2018-05-10

burnout syndrome is a significant problem in nursing professionals. Although, the unit where nurses work may influence burnout development. Nurses that work in primary care units may be at higher risk of burnout. The aim of the study was to estimate the prevalence of emotional exhaustion, depersonalization and low personal accomplishment in primary care nurses. We performed a meta-analysis. We searched Pubmed, CINAHL, Scopus, Scielo, Proquest, CUIDEN and LILACS databases up to September 2017 to identify cross-sectional studies assessing primary care nurses' burnout with the Maslach Burnout Inventory were included. The search was done in September 2017. After the search process, n = 8 studies were included in the meta-analysis, representing a total sample of n = 1110 primary care nurses. High emotional exhaustion prevalence was 28% (95% Confidence Interval = 22-34%), high depersonalization was 15% (95% Confidence Interval = 9-23%) and 31% (95% Confidence Interval = 6-66%) for low personal accomplishment. Problems such as emotional exhaustion and low personal accomplishment are very common among primary care nurses, while depersonalization is less prevalent. Primary care nurses are a burnout risk group.
The feasibility and acceptability of nurse-led chronic disease management interventions in primary care: An integrative review.

PubMed

Stephen, Catherine; McInnes, Susan; Halcomb, Elizabeth

2018-02-01

To explore the feasibility and acceptability of nurse-led chronic disease management and lifestyle risk factor reduction interventions in primary care (general practice/family practice). Growing international evidence suggests that interventions delivered by primary care nurses can assist in modifying lifestyle risk factors and managing chronic disease. To date, there has been limited exploration of the feasibility and acceptability of such interventions. Integrative review guided by the work of Whittemore and Knafl (). Database search of CINAHL, Medline and Web of Science was conducted to identify relevant literature published between 2000-2015. Papers were assessed for methodological quality and data abstracted before thematic analysis was undertaken. Eleven papers met the inclusion criteria. Analysis uncovered four themes: (1) facilitators of interventions; (2) barriers to interventions; (3) consumer satisfaction; and (4) primary care nurse role. Literature supports the feasibility and acceptability of nurse-led interventions in primary care for lifestyle risk factor modification. The ongoing sustainability of these interventions rests largely on organizational factors such as funding, educational pathways and professional support of the primary care nursing role. Further robust research around primary care nurse interventions is required to strengthen the evidence base. © 2017 John Wiley & Sons Ltd.

Review of Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention (Second edition).

PubMed

Ogbeide, Stacy A

2017-09-01

Reviews the book, Integrated Behavioral Health in Primary Care: Step-By-Step Guidance for Assessment and Intervention (Second Edition) by Anne C. Dobmeyer, Mark S. Oordt, Jeffrey L. Goodie, and Christopher L. Hunter (see record 2016-59132-000). This comprehensive book is well organized and covers many of the complex issues faced within the Primary Care Behavioral Health (PCBH) model and primary care setting: from uncontrolled type II diabetes to posttraumatic stress disorder. Primary care has changed since the initial release of this book, and the second edition covers many of these changes with up-to-date literature such as population health and the patient-centered medical home. The book is organized into three parts. The first three chapters describe the foundation of integrated behavioral consultation services. The next 12 chapters address common behavioral health issues that present in primary care. Last, the final two chapters focus on special topics such suicidal behavior and designing clinical pathways. This was an enjoyable read and worth the investment- especially if you are a trainee or a seasoned professional new to the practice of integrated behavioral health in primary care. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
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
Effectiveness of computerized clinical decision support systems for asthma and chronic obstructive pulmonary disease in primary care: a systematic review.

PubMed

Fathima, Mariam; Peiris, David; Naik-Panvelkar, Pradnya; Saini, Bandana; Armour, Carol Lyn

2014-12-02

The use of computerized clinical decision support systems may improve the diagnosis and ongoing management of chronic diseases, which requires recurrent visits to multiple health professionals, disease and medication monitoring and modification of patient behavior. The aim of this review was to systematically review randomized controlled trials evaluating the effectiveness of computerized clinical decision systems (CCDSS) in the care of people with asthma and COPD. Randomized controlled trials published between 2003 and 2013 were searched using multiple electronic databases Medline, EMBASE, CINAHL, IPA, Informit, PsychINFO, Compendex, and Cochrane Clinical Controlled Trials Register databases. To be included, RCTs had to evaluate the role of the CCDSSs for asthma and/or COPD in primary care. Nineteen studies representing 16 RCTs met our inclusion criteria. The majority of the trials were conducted in patients with asthma. Study quality was generally high. Meta-analysis was not conducted because of methodological and clinical heterogeneity. The use of CCDSS improved asthma and COPD care in 14 of the 19 studies reviewed (74%). Nine of the nineteen studies showed statistically significant (p < 0.05) improvement in the primary outcomes measured. The majority of the studies evaluated health care process measures as their primary outcomes (10/19). Evidence supports the effectiveness of CCDSS in the care of people with asthma. However there is very little information of its use in COPD care. Although there is considerable improvement in the health care process measures and clinical outcomes through the use of CCDSSs, its effects on user workload and efficiency, safety, costs of care, provider and patient satisfaction remain understudied.
What keeps you strong? A systematic review identifying how primary health-care and aged-care services can support the well-being of older Indigenous peoples.

PubMed

Davy, Carol; Kite, Elaine; Aitken, Graham; Dodd, Garth; Rigney, Janice; Hayes, Jenny; Van Emden, Jan

2016-06-01

The objective of this systematic review was to identify primary health-care or aged-care strategies that have or could support the well-being of older Indigenous peoples. A search was undertaken of primary databases including Medical Literature Analysis and Retrieval System Online and Cumulative Index to Nursing and Allied Health Literature. Papers which reported on the perspectives of older Indigenous peoples, community members and provider participants were included. Findings were pooled using a meta-aggregative approach. Three high-level synthesised findings - maintaining Indigenous identity, promoting independence and delivering culturally safe care - were believed to be important for supporting the well-being of older Indigenous peoples. As physical independence often diminishes with age, having the support of culturally safe primary health-care and aged-care services that understand the importance of maintaining an Indigenous identity and promoting independence will be crucial for the well-being of older Indigenous peoples. © 2016 AJA Inc.
Assessing conscientious personality in primary care: an opportunity for prevention and health promotion.

PubMed

Israel, Salomon; Moffitt, Terrie E

2014-05-01

The articles in this special section bolster the already strong evidence base that personality differences in the trait of conscientiousness predict health. What is now needed is a research agenda for translating documented risk associations between low conscientiousness and poor health into policies and interventions that improve health outcomes for individuals and populations. In this commentary, we highlight 1 such avenue: introducing brief personality assessment into primary care practice. We provide examples of how conscientiousness assessment may help health care professionals get to know their patients better and potentially serve as a guide for more personalized care. We also raise key considerations for implementation research aimed at examining the feasibility and utility of integrating conscientiousness assessment into primary care settings. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
Quality of asthma care under different primary care models in Canada: a population-based study.

PubMed

To, Teresa; Guan, Jun; Zhu, Jingqin; Lougheed, M Diane; Kaplan, Alan; Tamari, Itamar; Stanbrook, Matthew B; Simatovic, Jacqueline; Feldman, Laura; Gershon, Andrea S

2015-02-14

Previous research has shown variations in quality of care and patient outcomes under different primary care models. The objective of this study was to use previously validated, evidence-based performance indicators to measure quality of asthma care over time and to compare quality of care between different primary care models. Data were obtained for years 2006 to 2010 from the Ontario Asthma Surveillance Information System, which uses health administrative databases to track individuals with asthma living in the province of Ontario, Canada. Individuals with asthma (n=1,813,922) were divided into groups based on the practice model of their primary care provider (i.e., fee-for-service, blended fee-for-service, blended capitation). Quality of asthma care was measured using six validated, evidence-based asthma care performance indicators. All of the asthma performance indicators improved over time within each of the primary care models. Compared to the traditional fee-for-service model, the blended fee-for-service and blended capitation models had higher use of spirometry for asthma diagnosis and monitoring, higher rates of inhaled corticosteroid prescription, and lower outpatient claims. Emergency department visits were lowest in the blended fee-for-service group. Quality of asthma care improved over time within each of the primary care models. However, the amount by which they improved differed between the models. The newer primary care models (i.e., blended fee-for-service, blended capitation) appear to provide better quality of asthma care compared to the traditional fee-for-service model.
The Importance of Somatic Symptoms in Depression in Primary Care

PubMed Central

Tylee, André; Gandhi, Paul

2005-01-01

Objective: Patients with depression present with psychological and somatic symptoms, including general aches and pains. In primary care, somatic symptoms often dominate. A review of the literature was conducted to ascertain the importance of somatic symptoms in depression in primary care. Data sources and extraction: MEDLINE, EMBASE, and PsychLIT/PsychINFO databases (1985–January 2004) were searched for the terms depression, depressive, depressed AND physical, somatic, unexplained symptoms, complaints, problems; somatised, somatized symptoms; somatisation, somatization, somatoform, psychosomatic; pain; recognition, underrecognition; diagnosis, underdiagnosis; acknowledgment, underacknowledgment; treatment, undertreatment AND primary care, ambulatory care; primary physician; office; general practice; attribution, reattribution; and normalising, normalizing. Only English-language publications and abstracts were considered. Study selection: More than 80 papers related to somatic symptoms in depression were identified using the content of their titles and abstracts. Data synthesis: Approximately two thirds of patients with depression in primary care present with somatic symptoms. These patients are difficult to diagnose, feel an increased burden of disease, rely heavily on health care services, and are harder to treat. Patient and physician factors that prevent discussion of psychological symptoms during consultations must be overcome. Conclusions: Educational initiatives that raise awareness of somatic symptoms in depression and help patients to reattribute these symptoms should help to improve the recognition of depression in primary care. PMID:16163400
Humanization policy in primary health care: a systematic review

PubMed Central

Nora, Carlise Rigon Dalla; Junges, José Roque

2013-01-01

OBJECTIVE To analyze humanization practices in primary health care in the Brazilian Unified Health System according to the principles of the National Humanization Policy. METHODS A systematic review of the literature was carried out, followed by a meta-synthesis, using the following databases: BDENF (nursing database), BDTD (Brazilian digital library of theses and dissertations), CINAHL (Cumulative Index to nursing and allied health literature), LILACS (Latin American and Caribbean health care sciences literature), MedLine (International health care sciences literature), PAHO (Pan-American Health Care Organization Library) and SciELO (Scientific Electronic Library Online). The following descriptors were used: Humanization; Humanizing Health Care; Reception: Humanized care: Humanization in health care; Bonding; Family Health Care Program; Primary Care; Public Health and Sistema Único de Saúde (the Brazilian public health care system). Research articles, case studies, reports of experiences, dissertations, theses and chapters of books written in Portuguese, English or Spanish, published between 2003 and 2011, were included in the analysis. RESULTS Among the 4,127 publications found on the topic, 40 studies were evaluated and included in the analysis, producing three main categories: the first referring to the infrastructure and organization of the primary care service, made clear the dissatisfaction with the physical structure and equipment of the services and with the flow of attendance, which can facilitate or make difficult the access. The second, referring to the health work process, showed issues about the insufficient number of professionals, fragmentation of the work processes, the professional profile and responsibility. The third category, referring to the relational technologies, indicated the reception, bonding, listening, respect and dialog with the service users. CONCLUSIONS Although many practices were cited as humanizing they do not produce changes in the health services because of the lack of more profound analysis of the work processes and ongoing education in the health care services. PMID:24626556
Key elements of high-quality practice organisation in primary health care: a systematic review.

PubMed

Crossland, Lisa; Janamian, Tina; Jackson, Claire L

2014-08-04

To identify elements that are integral to high-quality practice and determine considerations relating to high-quality practice organisation in primary care. A narrative systematic review of published and grey literature. Electronic databases (PubMed, CINAHL, the Cochrane Library, Embase, Emerald Insight, PsycInfo, the Primary Health Care Research and Information Service website, Google Scholar) were searched in November 2013 and used to identify articles published in English from 2002 to 2013. Reference lists of included articles were searched for relevant unpublished articles and reports. Data were configured at the study level to allow for the inclusion of findings from a broad range of study types. Ten elements were most often included in the existing organisational assessment tools. A further three elements were identified from an inductive thematic analysis of descriptive articles, and were noted as important considerations in effective quality improvement in primary care settings. Although there are some validated tools available to primary care that identify and build quality, most are single-strategy approaches developed outside health care settings. There are currently no validated organisational improvement tools, designed specifically for primary health care, which combine all elements of practice improvement and whose use does not require extensive external facilitation.
A systematic review of chronic disease management interventions in primary care.

PubMed

Reynolds, Rebecca; Dennis, Sarah; Hasan, Iqbal; Slewa, Jan; Chen, Winnie; Tian, David; Bobba, Sangeetha; Zwar, Nicholas

2018-01-09

Primary and community care are key settings for the effective management of long term conditions. We aimed to evaluate the pattern of health outcomes in chronic disease management interventions for adults with physical health problems implemented in primary or community care settings. The methods were based on our previous review published in 2006. We performed database searches for articles published from 2006 to 2014 and conducted a systematic review with narrative synthesis using the Cochrane Effective Practice and Organisation of Care taxonomy to classify interventions and outcomes. The interventions were mapped to Chronic Care Model elements. The pattern of outcomes related to interventions was summarized by frequency of statistically significant improvements in health care provision and patient outcomes. A total of 9589 journal articles were retrieved from database searches and snowballing. After screening and verification, 165 articles that detailed 157 studies were included. There were few studies with Health Care Organization (1.9% of studies) or Community Resources (0.6% of studies) as the primary intervention element. Self-Management Support interventions (45.8% of studies) most frequently resulted in improvements in patient-level outcomes. Delivery System Design interventions (22.6% of studies) showed benefits in both professional and patient-level outcomes for a narrow range of conditions. Decision Support interventions (21.3% of studies) had impact limited to professional-level outcomes, in particular use of medications. The small number of studies of Clinical Information System interventions (8.9%) showed benefits for both professional- and patient-level outcomes. The published literature has expanded substantially since 2006. This review confirms that Self-Management Support is the most frequent Chronic Care Model intervention that is associated with statistically significant improvements, predominately for diabetes and hypertension.
Diagnostic accuracy of point-of-care natriuretic peptide testing for chronic heart failure in ambulatory care: systematic review and meta-analysis.

PubMed

Taylor, Kathryn S; Verbakel, Jan Y; Feakins, Benjamin G; Price, Christopher P; Perera, Rafael; Bankhead, Clare; Plüddemann, Annette

2018-05-21

To assess the diagnostic accuracy of point-of-care natriuretic peptide tests in patients with chronic heart failure, with a focus on the ambulatory care setting. Systematic review and meta-analysis. Ovid Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, Health Technology Assessment Database, Science Citation Index, and Conference Proceedings Citation Index until 31 March 2017. Eligible studies evaluated point-of-care natriuretic peptide testing (B-type natriuretic peptide (BNP) or N terminal fragment pro B-type natriuretic peptide (NTproBNP)) against any relevant reference standard, including echocardiography, clinical examination, or combinations of these, in humans. Studies were excluded if reported data were insufficient to construct 2×2 tables. No language restrictions were applied. 42 publications of 39 individual studies met the inclusion criteria and 40 publications of 37 studies were included in the analysis. Of the 37 studies, 30 evaluated BNP point-of-care testing and seven evaluated NTproBNP testing. 15 studies were done in ambulatory care settings in populations with a low prevalence of chronic heart failure. Five studies were done in primary care. At thresholds >100 pg/mL, the sensitivity of BNP, measured with the point-of-care index device Triage, was generally high and was 0.95 (95% confidence interval 0.90 to 0.98) at 100 pg/mL. At thresholds <100 pg/mL, sensitivity ranged from 0.46 to 0.97 and specificity from 0.31 to 0.98. Primary care studies that used NTproBNP testing reported a sensitivity of 0.99 (0.57 to 1.00) and specificity of 0.60 (0.44 to 0.74) at 135 pg/mL. No statistically significant difference in diagnostic accuracy was found between point-of-care BNP and NTproBNP tests. Given the lack of studies in primary care, the paucity of NTproBNP data, and potential methodological limitations in these studies, large scale trials in primary care are needed to assess the role of point-of-care natriuretic peptide testing and clarify appropriate thresholds to improve care of patients with suspected or chronic heart failure. 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.
A narrative systematic review of factors affecting diabetes prevention in primary care settings

PubMed Central

Eyles, Emily

2017-01-01

Background Type 2 diabetes is impacting millions of people globally; however, many future cases can be prevented through lifestyle changes and interventions. Primary care is an important setting for diabetes prevention, for at-risk populations, because it is a patient’s primary point of contact with the health care system and professionals can provide lifestyle counselling and support, as well as monitoring health outcomes. These are all essential elements for diabetes prevention for at-risk adults. Aim To understand the factors related to the delivery and uptake of type 2 diabetes prevention interventions within primary care in higher income countries. Methods For this narrative systematic review, we combined qualitative and quantitative studies of diabetes prevention within a primary care setting for patients at-risk of developing the condition. We used an iterative approach for evidence collection, which included using several databases (MEDLINE, Embase, Pysch info, BNI, SSCI, CINAHL, ASSIA), where we combined diabetes terms with primary care terms. Narrative and thematic synthesis were utilised to identify the prominent themes emerging from the data. Results A database of 6646 records was screened by the research team, and 18 papers were included. Three major themes were identified in this review. The first theme of context and setting of diabetes progression includes the risk and progression of diabetes, primary care as a setting, and where the responsibility for change is thought to lie. This review also found mixed views on the value of preventative services within primary care. The second theme focused on the various patient factors associated with diabetes prevention such as a patient’s motivation to modify their current lifestyle, perceptions and knowledge (or lack thereof) of the impacts of diabetes, lack of follow-up in healthcare settings, and trust in healthcare professionals. The third theme was centred on professional factors impacting on diabetes prevention which included workload, time constraints, resources, self-efficacy and knowledge as well as professionals’ perception of patient motivations towards change. Conclusion This review explored the factors influencing diabetes prevention in primary care, and identified the context of prevention, as well as patient and professional factors related to preventative services being offered in primary care. This systematic review complements previous reviews of real-world settings by exploring the significant factors in prevention, and the findings are relevant to academics, policymakers, patients and practitioners interested in understanding the factors associated with the delivery and uptake of diabetes prevention interventions. PMID:28531197
Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis.

PubMed

Stokes, Jonathan; Panagioti, Maria; Alam, Rahul; Checkland, Kath; Cheraghi-Sohi, Sudeh; Bower, Peter

2015-01-01

An ageing population with multimorbidity is putting pressure on health systems. A popular method of managing this pressure is identification of patients in primary care 'at-risk' of hospitalisation, and delivering case management to improve outcomes and avoid admissions. However, the effectiveness of this model has not been subjected to rigorous quantitative synthesis. We carried out a systematic review and meta-analysis of the effectiveness of case management for 'at-risk' patients in primary care. Six bibliographic databases were searched using terms for 'case management', 'primary care', and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across a number of relevant outcomes: Health--self-assessed health status, mortality; Cost--total cost of care, healthcare utilisation (primary and non-specialist care and secondary care separately), and; Satisfaction--patient satisfaction. We conducted secondary subgroup analyses to assess whether effectiveness was moderated by the particular model of case management, context, and study design. A total of 15,327 titles and abstracts were screened, 36 unique studies were included. Meta-analyses showed no significant differences in total cost, mortality, utilisation of primary or secondary care. A very small significant effect favouring case management was found for self-reported health status in the short-term (0.07, 95% CI 0.00 to 0.14). A small significant effect favouring case management was found for patient satisfaction in the short- (0.26, 0.16 to 0.36) and long-term (0.35, 0.04 to 0.66). Secondary subgroup analyses suggested the effectiveness of case management may be increased when delivered by a multidisciplinary team, when a social worker was involved, and when delivered in a setting rated as low in initial 'strength' of primary care. This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs. We consider reasons for lack of effect and highlight key research questions for the future. The review protocol is available as part of the PROSPERO database (registration number: CRD42014010824).
Predictors of hypoglycaemia in insulin-treated type 2 diabetes patients in primary care: a retrospective database analysis.

PubMed

Kostev, Karel; Dippel, Franz-Werner; Rathmann, Wolfgang

2014-07-01

To investigate the frequency and predictors (diabetes care and treatment, comorbidity) of documented hypoglycaemia in primary care patients with insulin-treated type 2 diabetes. Data from 32,545 patients (mean age: 70 (SD 11) years, 50.3% males) from 1072 practices were retrospectively analyzed (Disease Analyzer database Germany: 09/2011-08/2012). Logistic regression (≥1 documented hypoglyemia) was used to adjust for confounders (age, sex, practice characteristics, diabetes treatment regimen). The prevalence of patients (12 months) with at least one reported hypoglycaemia was 2.2% (95% CI: 2.0-2.4%). The adjusted odds of having hypoglycemia were increased for renal failure (OR; 95% CI: 1.26; 1.16-1.37), autonomic neuropathy (1.34; 1.20-1.49), and adrenocortical insufficiency (3.08; 1.35-7.05). Patients with mental disorders including dementia (1.49; 1.31-1.69), depression (1.24; 1.13-1.35), anxiety (1.18; 1.01-1.37), and affective disorders (1.80; 1.36-2.38) also showed an increased odds of having hypoglycemia. Location of the practice in an urban area was associated with a lower odds ratio (0.74; 0.68-0.80). Both individual patient characteristics (e.g. comorbidity) and regional factors (practice location) have a substantial impact on hypoglycaemia in primary care patients with insulin therapy. Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
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.
How do primary care physicians seek answers to clinical questions? A literature review.

PubMed

Coumou, Herma C H; Meijman, Frans J

2006-01-01

The authors investigated the extent to which changes occurred between 1992 and 2005 in the ways that primary care physicians seek answers to clinical problems. What search strategies are used? How much time is spent on them? How do primary care physicians evaluate various search activities and information sources? Can a clinical librarian be useful to a primary care physician? Twenty-one original research papers and three literature reviews were examined. No systematic reviews were identified. Primary care physicians seek answers to only a limited number of questions about which they first consult colleagues and paper sources. This practice has basically not changed over the years despite the enormous increase in and better accessibility to electronic information sources. One of the major obstacles is the time it takes to search for information. Other difficulties primary care physicians experience are related to formulating an appropriate search question, finding an optimal search strategy, and interpreting the evidence found. Some studies have been done on the supporting role of a clinical librarian in general practice. However, the effects on professional behavior of the primary care physician and on patient outcome have not been studied. A small group of primary care physicians prefer this support to developing their own search skills. Primary care physicians have several options for finding quick answers: building a question-and-answer database, consulting filtered information sources, or using an intermediary such as a clinical librarian.
How do primary care physicians seek answers to clinical questions? A literature review

PubMed Central

Coumou, Herma C. H.; Meijman, Frans J.

2006-01-01

Objectives: The authors investigated the extent to which changes occurred between 1992 and 2005 in the ways that primary care physicians seek answers to clinical problems. What search strategies are used? How much time is spent on them? How do primary care physicians evaluate various search activities and information sources? Can a clinical librarian be useful to a primary care physician? Methods: Twenty-one original research papers and three literature reviews were examined. No systematic reviews were identified. Results: Primary care physicians seek answers to only a limited number of questions about which they first consult colleagues and paper sources. This practice has basically not changed over the years despite the enormous increase in and better accessibility to electronic information sources. One of the major obstacles is the time it takes to search for information. Other difficulties primary care physicians experience are related to formulating an appropriate search question, finding an optimal search strategy, and interpreting the evidence found. Some studies have been done on the supporting role of a clinical librarian in general practice. However, the effects on professional behavior of the primary care physician and on patient outcome have not been studied. A small group of primary care physicians prefer this support to developing their own search skills. Discussion: Primary care physicians have several options for finding quick answers: building a question-and-answer database, consulting filtered information sources, or using an intermediary such as a clinical librarian. PMID:16404470
Factors affecting subspecialty referrals by pediatric primary care providers for children with obesity-related comorbidities.

PubMed

Walsh, Carolyn O; Milliren, Carly E; Feldman, Henry A; Taveras, Elsie M

2013-08-01

To determine referral patterns from pediatric primary care to subspecialists for overweight/obesity and related comorbidities. We used the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to identify overweight/obesity and 5 related comorbidities in primary care visits between 2005 and 2009 by children 6 to 18 years. The primary outcome was whether the visit ended in referral. We used multivariable analysis to examine factors associated with referral. We identified 34,225 database visits. A total of 17.1% were with overweight (body mass index=85th to 94th percentile) or obese (body mass index≥95th percentile) patients. A total of 7.1% of primary care visits with overweight/obese children ended in referral. Referral was more likely when obesity was the reason for visit (odds ratio=2.83; 95% confidence interval=1.61-4.97) but was not associated with presence of a comorbidity (odds ratio=1.35; 95% confidence interval=0.75-2.44). Most overweight or obese children are not referred, regardless of comorbidity status. One reason may be low levels of appropriate diagnosis.
Identification of physicians providing comprehensive primary care in Ontario: a retrospective analysis using linked administrative data.

PubMed

Schultz, Susan E; Glazier, Richard H

2017-12-19

Given the changing landscape of primary care, there may be fewer primary care physicians available to provide a broad range of services to patients of all age groups and health conditions. We sought to identify physicians with comprehensive primary care practices in Ontario using administrative data, investigating how many and what proportion of primary care physicians provided comprehensive primary care and how this changed over time. We identified the pool of active primary care physicians in linked population-based databases for Ontario from 1992/93 to 2014/15. After excluding those who saw patients fewer than 44 days per year, we identified physicians as providing comprehensive care if more than half of their services were for core primary care and if these services fell into at least 7 of 22 activity areas. Physicians with 50% or less of their services for core primary care but with more than 50% in a single location or type of service were identified as being in focused practice. In 2014/15, there were 12 891 physicians in the primary care pool: 1254 (9.7%) worked fewer than 44 days per year, 1619 (12.6%) were in focused practice, and 1009 (7.8%) could not be classified. The proportion in comprehensive practice ranged from 67.5% to 74.9% between 1992/93 and 2014/15, with a peak in 2002/03 and relative stability from 2009/10 to 2014/15. Over this period, there was an increase of 8.8% in population per comprehensive primary care physician. We found that just over two-thirds of primary care physicians provided comprehensive care in 2014/15, which indicates that traditional estimates of the primary care physician workforce may be too high. Although implementation will vary by setting and available data, this approach is likely applicable elsewhere. Copyright 2017, Joule Inc. or its licensors.
Modelling Conditions and Health Care Processes in Electronic Health Records: An Application to Severe Mental Illness with the Clinical Practice Research Datalink.

PubMed

Olier, Ivan; Springate, David A; Ashcroft, Darren M; Doran, Tim; Reeves, David; Planner, Claire; Reilly, Siobhan; Kontopantelis, Evangelos

2016-01-01

The use of Electronic Health Records databases for medical research has become mainstream. In the UK, increasing use of Primary Care Databases is largely driven by almost complete computerisation and uniform standards within the National Health Service. Electronic Health Records research often begins with the development of a list of clinical codes with which to identify cases with a specific condition. We present a methodology and accompanying Stata and R commands (pcdsearch/Rpcdsearch) to help researchers in this task. We present severe mental illness as an example. We used the Clinical Practice Research Datalink, a UK Primary Care Database in which clinical information is largely organised using Read codes, a hierarchical clinical coding system. Pcdsearch is used to identify potentially relevant clinical codes and/or product codes from word-stubs and code-stubs suggested by clinicians. The returned code-lists are reviewed and codes relevant to the condition of interest are selected. The final code-list is then used to identify patients. We identified 270 Read codes linked to SMI and used them to identify cases in the database. We observed that our approach identified cases that would have been missed with a simpler approach using SMI registers defined within the UK Quality and Outcomes Framework. We described a framework for researchers of Electronic Health Records databases, for identifying patients with a particular condition or matching certain clinical criteria. The method is invariant to coding system or database and can be used with SNOMED CT, ICD or other medical classification code-lists.

[Organization of traditional Primary Health Care and the Family Health Program in large cities in Rio de Janeiro State, Brazil].

PubMed

Machado, Cristiani Vieira; Lima, Luciana Dias de; Silva Viana, Ludmilla da

2008-01-01

This article analyzes the organization of traditional Primary Health Care and the Family Health Program (FHP) in the 22 municipalities of Rio de Janeiro State, Brazil, with more than 100,000 inhabitants each in 2005. The methodology included visits to the municipalities, interviews with health managers, and analysis of national databases. Four summary variables were defined: the Primary Health Care model and inclusion of the FHP; institutionalization of the FHP; organization of traditional primary care; and organization of the FHP. Classification of the municipalities according to the four variables showed widely diverse situations and the predominance of a parallel model for inclusion of the FHP. The municipalities with the best structural conditions for primary care are located in the interior of the State, besides those that have had the FHP implemented for more than six years and that practice various modalities of Primary Health Care organization. The majority of the municipalities with the worst situation in relation to the FHP are located in Greater Metropolitan Rio de Janeiro. In light of the results, the article discusses the challenges facing the FHP as a strategy for structuring primary health care in large cities, particularly in metropolitan areas.
Building a pan-Canadian primary care sentinel surveillance network: initial development and moving forward.

PubMed

Birtwhistle, Richard; Keshavjee, Karim; Lambert-Lanning, Anita; Godwin, Marshall; Greiver, Michelle; Manca, Donna; Lagacé, Claudia

2009-01-01

The development of a pan-Canadian network of primary care research networks for studying issues in primary care has been the vision of Canadian primary care researchers for many years. With the opportunity for funding from the Public Health Agency of Canada and the support of the College of Family Physicians of Canada, we have planned and developed a project to assess the feasibility of a network of networks of family medicine practices that exclusively use electronic medical records. The Canadian Primary Care Sentinel Surveillance Network will collect longitudinal data from practices across Canada to assess the primary care epidemiology and management of 5 chronic diseases: hypertension, diabetes, depression, chronic obstructive lung disease, and osteoarthritis. This article reports on the 7-month first phase of the feasibility project of 7 regional networks in Canada to develop a business plan, including governance, mission, and vision; develop memorandum of agreements with the regional networks and their respective universities; develop and obtain approval of research ethics board applications; develop methods for data extraction, a Canadian Primary Care Sentinel Surveillance Network database, and initial assessment of the types of data that can be extracted; and recruitment of 10 practices at each network that use electronic medical records. The project will continue in phase 2 of the feasibility testing until April 2010.
Minding the gap and overlap: a literature review of fragmentation of primary care for chronic dialysis patients.

PubMed

Wang, Virginia; Diamantidis, Clarissa J; Wylie, JaNell; Greer, Raquel C

2017-08-29

Care coordination is a challenge for patients with kidney disease, who often see multiple providers to manage their associated complex chronic conditions. Much of the focus has been on primary care physician (PCP) and nephrologist collaboration in the early stages of chronic kidney disease, but less is known about the co-management of the patients in the end-stage of renal disease. We conducted a systematic review and synthesis of empirical studies on primary care services for dialysis patients. Systematic literature search of MEDLINE/PubMED, CINAHL, and EmBase databases for studies, published until August 2015. Inclusion criteria included publications in English, empirical studies involving human subjects (e.g., patients, physicians), conducted in US and Canadian study settings that evaluated primary care services in the dialysis patient population. Fourteen articles examined three major themes of primary care services for dialysis patients: perceived roles of providers, estimated time in providing primary care, and the extent of dialysis patients' use of primary care services. There was general agreement among providers that PCPs should be involved but time, appropriate roles, and miscommunication are potential barriers to good primary care for dialysis patients. Although many dialysis patients report having a PCP, the majority rely on primary care from their nephrologists. Studies using administrative data found lower rates of preventive care services than found in studies relying on provider or patient self-report. The extant literature revealed gaps and opportunities to optimize primary care services for dialysis patients, foreshadowing the challenges and promise of Accountable Care / End-Stage Seamless Care Organizations and care coordination programs currently underway in the United States to improve clinical and logistical complexities of care for this commonly overlooked population. Studies linking the relationship between providers and patients' receipt of primary care to outcomes will serve as important comparisons to the nascent care models for ESRD patients, whose value is yet to be determined.
[The interface between primary and secondary care in dentistry in the Unified Health System (SUS): an integrative systematic review].

PubMed

Silva, Helbert Eustáquio Cardoso da; Gottems, Leila Bernarda Donato

2017-08-01

Secondary care in dentistry in Brazil has scarce and broadly underutilized resources. The challenge is to organize the interface between primary health care (PHC) and secondary care in order to consolidate the population's access to specialist dental care in the Unified Health System (SUS). This article seeks to analyze national publications in Portuguese and English on the interface between secondary health care and primary health care in dentistry from the perspective of comprehensive care in the SUS. It is an integrative review, considering the publications of the following databases: SciELO (Scientific Electronic Library Online), LILACS (Latin American and Caribbean Literature) WEB OF SCIENCE, SCOPUS, PubMed (International Literature on Health Sciences) and GOOGLE SCHOLAR. The search located 966 articles, of which 12 were used in full. Coverage of the oral health teams (ESB) in the family health strategy (ESF), primary health care implementation in a structured way, access to secondary health care, counter-referral to PHC, development of indicators and socioeconomic conditions and inequalities in the distribution of dental specialist centers (CEO) are factors that influence the integrity of oral health care in the SUS.
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).
Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis

PubMed Central

Stokes, Jonathan; Panagioti, Maria; Alam, Rahul; Checkland, Kath; Cheraghi-Sohi, Sudeh; Bower, Peter

2015-01-01

Background An ageing population with multimorbidity is putting pressure on health systems. A popular method of managing this pressure is identification of patients in primary care ‘at-risk’ of hospitalisation, and delivering case management to improve outcomes and avoid admissions. However, the effectiveness of this model has not been subjected to rigorous quantitative synthesis. Methods and Findings We carried out a systematic review and meta-analysis of the effectiveness of case management for ‘at-risk’ patients in primary care. Six bibliographic databases were searched using terms for ‘case management’, ‘primary care’, and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across a number of relevant outcomes: Health – self-assessed health status, mortality; Cost – total cost of care, healthcare utilisation (primary and non-specialist care and secondary care separately), and; Satisfaction – patient satisfaction. We conducted secondary subgroup analyses to assess whether effectiveness was moderated by the particular model of case management, context, and study design. A total of 15,327 titles and abstracts were screened, 36 unique studies were included. Meta-analyses showed no significant differences in total cost, mortality, utilisation of primary or secondary care. A very small significant effect favouring case management was found for self-reported health status in the short-term (0.07, 95% CI 0.00 to 0.14). A small significant effect favouring case management was found for patient satisfaction in the short- (0.26, 0.16 to 0.36) and long-term (0.35, 0.04 to 0.66). Secondary subgroup analyses suggested the effectiveness of case management may be increased when delivered by a multidisciplinary team, when a social worker was involved, and when delivered in a setting rated as low in initial ‘strength’ of primary care. Conclusions This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs. We consider reasons for lack of effect and highlight key research questions for the future. Review Protocol The review protocol is available as part of the PROSPERO database (registration number: CRD42014010824). PMID:26186598
Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care.

PubMed

Paton, Fiona; Wright, Kath; Ayre, Nigel; Dare, Ceri; Johnson, Sonia; Lloyd-Evans, Brynmor; Simpson, Alan; Webber, Martin; Meader, Nick

2016-01-01

Crisis Concordat was established to improve outcomes for people experiencing a mental health crisis. The Crisis Concordat sets out four stages of the crisis care pathway: (1) access to support before crisis point; (2) urgent and emergency access to crisis care; (3) quality treatment and care in crisis; and (4) promoting recovery. To evaluate the clinical effectiveness and cost-effectiveness of the models of care for improving outcomes at each stage of the care pathway. Electronic databases were searched for guidelines, reviews and, where necessary, primary studies. The searches were performed on 25 and 26 June 2014 for NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database, and the Health Technology Assessment (HTA) and PROSPERO databases, and on 11 November 2014 for MEDLINE, PsycINFO and the Criminal Justice Abstracts databases. Relevant reports and reference lists of retrieved articles were scanned to identify additional studies. When guidelines covered a topic comprehensively, further literature was not assessed; however, where there were gaps, systematic reviews and then primary studies were assessed in order of priority. Systematic reviews were critically appraised using the Risk Of Bias In Systematic reviews assessment tool, trials were assessed using the Cochrane risk-of-bias tool, studies without a control group were assessed using the National Institute for Health and Care Excellence (NICE) prognostic studies tool and qualitative studies were assessed using the Critical Appraisal Skills Programme quality assessment tool. A narrative synthesis was conducted for each stage of the care pathway structured according to the type of care model assessed. The type and range of evidence identified precluded the use of meta-analysis. One review of reviews, six systematic reviews, nine guidelines and 15 primary studies were included. There was very limited evidence for access to support before crisis point. There was evidence of benefits for liaison psychiatry teams in improving service-related outcomes in emergency departments, but this was often limited by potential confounding in most studies. There was limited evidence regarding models to improve urgent and emergency access to crisis care to guide police officers in their Mental Health Act responsibilities. There was positive evidence on clinical effectiveness and cost-effectiveness of crisis resolution teams but variability in implementation. Current work from the Crisis resolution team Optimisation and RElapse prevention study aims to improve fidelity in delivering these models. Crisis houses and acute day hospital care are also currently recommended by NICE. There was a large evidence base on promoting recovery with a range of interventions recommended by NICE likely to be important in helping people stay well. Most evidence was rated as low or very low quality, but this partly reflects the difficulty of conducting research into complex interventions for people in a mental health crisis and does not imply that all research was poorly conducted. However, there are currently important gaps in research for a number of stages of the crisis care pathway. Particular gaps in research on access to support before crisis point and urgent and emergency access to crisis care were found. In addition, more high-quality research is needed on the clinical effectiveness and cost-effectiveness of mental health crisis care, including effective components of inpatient care, post-discharge transitional care and Community Mental Health Teams/intensive case management teams. This study is registered as PROSPERO CRD42014013279. The National Institute for Health Research HTA programme.
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.
Online medical care: the current state of "eVisits" in acute primary care delivery.

PubMed

Hickson, Ryan; Talbert, Jeffery; Thornbury, William C; Perin, Nathan R; Goodin, Amie J

2015-02-01

Online technologies offer the promise of an efficient, improved healthcare system. Patients benefit from increased access to care, physicians are afforded greater flexibility in care delivery, and the health system itself benefits from lower costs to provide such care. One method of incorporating online care into clinical practice, called electronic office visits or "eVisits," allows physicians to provide a consultation with patients online. We performed an analysis of the current published literature on eVisits as well as present emerging research describing the use of mobile platforms as the delivery model. We focused on the role of eVisits in acute primary care practice. A literature review was conducted using electronic databases with a variety of search terms related to the use of eVisits in primary care. Several advantages to eVisit utilization in the primary care setting were identified, namely, improvements in efficiency, continuity of care, quality of care, and access to care. Barriers to eVisit implementation were also identified, including challenges with incorporation into workflow, reimbursement, physician technological literacy, patient health literacy, overuse, security, confidentiality, and integration with existing medical technologies. Only one study of patient satisfaction with eVisit acute primary care services was identified, and this suggests that previous analyses of eVisit utilization are lacking this key component of healthcare service delivery evaluations. The delivery of primary care via eVisits on mobile platforms is still in adolescence, with few methodologically rigorous analyses of outcomes of efficiency, patient health, and satisfaction.
The effects of organization on medical utilization: an analysis of service line organization.

PubMed

Byrne, Margaret M; Charns, Martin P; Parker, Victoria A; Meterko, Mark M; Wray, Nelda P

2004-01-01

To determine whether clinical service lines in primary care and mental health reduces inpatient and urgent care utilization. All VHA medical centers were surveyed to determine whether service lines had been established in primary care or mental health care prior to the beginning of fiscal year 1997 (FY97). Facility-level data on medical utilization from Veterans Health Affairs (VHA) administrative databases were used for descriptive and multivariate regression analyses of utilization and of changes in measures between FY97 and FY98. Nine primary care-related and 5 mental health-related variables were analyzed. Primary care and mental health service lines had been established in approximately half of all facilities. Service lines varied in duration and extent of restructuring. Mere presence of a service line had no positive and several negative effects on measured outcome variables. More detailed analyses showed that some types of service lines have statistically significant and mostly negative effects on both mental health and primary care-related measures. Newly implemented service lines had significantly less improvement in measures over time than facilities with no service line. Health care organizations are implementing innovative organizational structures in hopes of improving quality of care and reducing resource utilization. We found that service lines in primary care and mental health may lead to an initial period of disruption, with little evidence of a beneficial effect on performance for longer duration service lines.
Predicting Use of Nurse Care Coordination by Older Adults With Chronic Conditions.

PubMed

Vanderboom, Catherine E; Holland, Diane E; Mandrekar, Jay; Lohse, Christine M; Witwer, Stephanie G; Hunt, Vicki L

2017-07-01

To be effective, nurse care coordination must be targeted at individuals who will use the service. The purpose of this study was to identify variables that predicted use of care coordination by primary care patients. Data on the potential predictor variables were obtained from patient interviews, the electronic health record, and an administrative database of 178 adults eligible for care coordination. Use of care coordination was obtained from an administrative database. A multivariable logistic regression model was developed using a bootstrap sampling approach. Variables predicting use of care coordination were dependence in both activities of daily living (ADL) and instrumental activities of daily living (IADL; odds ratio [OR] = 5.30, p = .002), independent for ADL but dependent for IADL (OR = 2.68, p = .01), and number of prescription medications (OR = 1.12, p = .002). Consideration of these variables may improve identification of patients to target for care coordination.
Comparison of dementia recorded in routinely collected hospital admission data in England with dementia recorded in primary care.

PubMed

Brown, Anna; Kirichek, Oksana; Balkwill, Angela; Reeves, Gillian; Beral, Valerie; Sudlow, Cathie; Gallacher, John; Green, Jane

2016-01-01

Electronic linkage of UK cohorts to routinely collected National Health Service (NHS) records provides virtually complete follow-up for cause-specific hospital admissions and deaths. The reliability of dementia diagnoses recorded in NHS hospital data is not well documented. For a sample of Million Women Study participants in England we compared dementia recorded in routinely collected NHS hospital data (Hospital Episode Statistics: HES) with dementia recorded in two separate sources of primary care information: a primary care database [Clinical Practice Research Datalink (CPRD), n = 340] and a survey of study participants' General Practitioners (GPs, n = 244). Dementia recorded in HES fully agreed both with CPRD and with GP survey data for 85% of women; it did not agree for 1 and 4%, respectively. Agreement was uncertain for the remaining 14 and 11%, respectively; and among those classified as having uncertain agreement in CPRD, non-specific terms compatible with dementia, such as 'memory loss', were recorded in the CPRD database for 79% of the women. Agreement was significantly better (p < 0.05 for all comparisons) for women with HES diagnoses for Alzheimer's disease (95 and 94% agreement with any dementia for CPRD and GP survey, respectively) and for vascular dementia (88 and 88%, respectively) than for women with a record only of dementia not otherwise specified (70 and 72%, respectively). Dementia in the same woman was first mentioned an average 1.6 (SD 2.6) years earlier in primary care (CPRD) than in hospital (HES) data. Age-specific rates for dementia based on the hospital admission data were lower than the rates based on the primary care data, but were similar if the delay in recording in HES was taken into account. Dementia recorded in routinely collected NHS hospital admission data for women in England agrees well with primary care records of dementia assessed separately from two different sources, and is sufficiently reliable for epidemiological research.
St. Louis Initiative for Integrated Care Excellence (SLI(2)CE): integrated-collaborative care on a large scale model.

PubMed

Brawer, Peter A; Martielli, Richard; Pye, Patrice L; Manwaring, Jamie; Tierney, Anna

2010-06-01

The primary care health setting is in crisis. Increasing demand for services, with dwindling numbers of providers, has resulted in decreased access and decreased satisfaction for both patients and providers. Moreover, the overwhelming majority of primary care visits are for behavioral and mental health concerns rather than issues of a purely medical etiology. Integrated-collaborative models of health care delivery offer possible solutions to this crisis. The purpose of this article is to review the existing data available after 2 years of the St. Louis Initiative for Integrated Care Excellence; an example of integrated-collaborative care on a large scale model within a regional Veterans Affairs Health Care System. There is clear evidence that the SLI(2)CE initiative rather dramatically increased access to health care, and modified primary care practitioners' willingness to address mental health issues within the primary care setting. In addition, data suggests strong fidelity to a model of integrated-collaborative care which has been successful in the past. Integrated-collaborative care offers unique advantages to the traditional view and practice of medical care. Through careful implementation and practice, success is possible on a large scale model. PsycINFO Database Record (c) 2010 APA, all rights reserved.
Primary Care Patients' Preference for Hospitals over Clinics in Korea.

PubMed

Kim, Agnus M; Cho, Seongcheol; Kim, Hyun Joo; Jung, Hyemin; Jo, Min-Woo; Lee, Jin Yong; Eun, Sang Jun

2018-05-30

Korea is in a unique condition to observe whether patients, when equal access to the levels of health care facilities is guaranteed by the support of the national health insurance, choose the appropriate levels of health care facilities. This study was performed to investigate the primary care patients' preference for hospitals over clinics under no restriction for their choice. We used the 2011 National Inpatient Sample database of the Health Insurance Review and Assessment Service in Korea. A primary care patient was defined as a patient who visited as an outpatient in health care facilities with one of the 52 minor conditions defined by the Korean government. We found that approximately 15% of outpatient visits of the patients who were eligible for primary care in Korea happened in hospitals. In terms of cost, the outpatient visits in hospitals accounted for about 29% of total cost of outpatient visits. This arbitrary access to hospitals can lead to an inefficient use of health care resources. In order to ensure that health care facilities are stratified in terms of access as well as size and function, interventions to distribute patients to the appropriate level of care are required.
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.
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.
The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review

PubMed Central

Stellefson, Michael; Stopka, Christine

2013-01-01

Introduction The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation. Methods We conducted a literature review by using the Cochrane database of systematic reviews, CINAHL, and Health Source: Nursing/Academic Edition and the following search terms: “chronic care model” (and) “diabet*.” We included articles published between January 1999 and October 2011. We summarized details on CCM application and health outcomes for 16 studies. Results The 16 studies included various study designs, including 9 randomized controlled trials, and settings, including academic-affiliated primary care practices and private practices. We found evidence that CCM approaches have been effective in managing diabetes in US primary care settings. Organizational leaders in health care systems initiated system-level reorganizations that improved the coordination of diabetes care. Disease registries and electronic medical records were used to establish patient-centered goals, monitor patient progress, and identify lapses in care. Primary care physicians (PCPs) were trained to deliver evidence-based care, and PCP office–based diabetes self-management education improved patient outcomes. Only 7 studies described strategies for addressing community resources and policies. Conclusion CCM is being used for diabetes care in US primary care settings, and positive outcomes have been reported. Future research on integration of CCM into primary care settings for diabetes management should measure diabetes process indicators, such as self-efficacy for disease management and clinical decision making. PMID:23428085
Validation study in four health-care databases: upper gastrointestinal bleeding misclassification affects precision but not magnitude of drug-related upper gastrointestinal bleeding risk.

PubMed

Valkhoff, Vera E; Coloma, Preciosa M; Masclee, Gwen M C; Gini, Rosa; Innocenti, Francesco; Lapi, Francesco; Molokhia, Mariam; Mosseveld, Mees; Nielsson, Malene Schou; Schuemie, Martijn; Thiessard, Frantz; van der Lei, Johan; Sturkenboom, Miriam C J M; Trifirò, Gianluca

2014-08-01

To evaluate the accuracy of disease codes and free text in identifying upper gastrointestinal bleeding (UGIB) from electronic health-care records (EHRs). We conducted a validation study in four European electronic health-care record (EHR) databases such as Integrated Primary Care Information (IPCI), Health Search/CSD Patient Database (HSD), ARS, and Aarhus, in which we identified UGIB cases using free text or disease codes: (1) International Classification of Disease (ICD)-9 (HSD, ARS); (2) ICD-10 (Aarhus); and (3) International Classification of Primary Care (ICPC) (IPCI). From each database, we randomly selected and manually reviewed 200 cases to calculate positive predictive values (PPVs). We employed different case definitions to assess the effect of outcome misclassification on estimation of risk of drug-related UGIB. PPV was 22% [95% confidence interval (CI): 16, 28] and 21% (95% CI: 16, 28) in IPCI for free text and ICPC codes, respectively. PPV was 91% (95% CI: 86, 95) for ICD-9 codes and 47% (95% CI: 35, 59) for free text in HSD. PPV for ICD-9 codes in ARS was 72% (95% CI: 65, 78) and 77% (95% CI: 69, 83) for ICD-10 codes (Aarhus). More specific definitions did not have significant impact on risk estimation of drug-related UGIB, except for wider CIs. ICD-9-CM and ICD-10 disease codes have good PPV in identifying UGIB from EHR; less granular terminology (ICPC) may require additional strategies. Use of more specific UGIB definitions affects precision, but not magnitude, of risk estimates. Copyright © 2014 Elsevier Inc. All rights reserved.
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.
Connecting the dots and merging meaning: using mixed methods to study primary care delivery transformation.

PubMed

Scammon, Debra L; Tomoaia-Cotisel, Andrada; Day, Rachel L; Day, Julie; Kim, Jaewhan; Waitzman, Norman J; Farrell, Timothy W; Magill, Michael K

2013-12-01

To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. Convergent case study mixed methods design. Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence. © Health Research and Educational Trust.

Connecting the Dots and Merging Meaning: Using Mixed Methods to Study Primary Care Delivery Transformation

PubMed Central

Scammon, Debra L; Tomoaia-Cotisel, Andrada; Day, Rachel L; Day, Julie; Kim, Jaewhan; Waitzman, Norman J; Farrell, Timothy W; Magill, Michael K

2013-01-01

Objective. To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. Data Source/Study Setting. An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. Study Design. Convergent case study mixed methods design. Data Collection/Extraction Methods. Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. Principal Findings. Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. Conclusions. Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence. PMID:24279836
Clinical presentation and management of stable coronary artery disease in Austria.

PubMed

Pichlhöfer, Otto; Maier, Manfred; Badr-Eslam, Roza; Ristl, Robin; Zebrowska, Magdalena; Lang, Irene M

2017-01-01

Cardiovascular disease is the main cause of death in Austria. However, no systematic information exists regarding characteristics and treatments of contemporary patients with stable coronary artery disease (CAD) in Austria. We assembled two retrospective physicians' databases to describe demographics, clinical profiles, and therapeutic strategies in patients with stable CAD. In addition, we compared patient profiles of secondary care internists and hospital-based cardiologists with those of general practitioners in a primary care setting outside of hospital. The study population was identified from retrospective chart review of 1020 patients from 106 primary care physicians in Austria (ProCor II registry), and was merged with a previous similar database of 1280 patients under secondary care (ProCor I registry) to yield a total patient number of 2300. Female patients with stable CAD were older, had more angina and/or heart failure symptoms, and more depression than males. Female gender, type 2 diabetes mellitus, higher CCS class and asthma/COPD were predictors of elevated heart rate, while previous coronary events/revascularization predicted a lower heart rate in multivariate analysis. There were no significant differences with regard to characteristics and management of patients of general practitioners in the primary care setting versus internists in secondary care. Characteristics and treatments of unselected patients with stable ischemic heart disease in Austria resemble the pattern of large international registries of stable ischemic heart disease, with the exception that diabetes and systemic hypertension were more prevalent.
Utility of routinely acquired primary care data for paediatric disease epidemiology and pharmacoepidemiology

PubMed Central

Helms, Peter J; Daukes, Suzie Ekins; Taylor, Michael W; Simpson, Colin R; McLay, James S

2005-01-01

Background The majority of medicines prescribed for children are prescribed in primary care for common acute and chronic conditions. This is in contrast to prescribing in secondary care where the population of children admitted is small but where a large number of different medicines are prescribed to treat more serious and less common conditions. Methods Data on prescribing was extracted from the General Practice Administration System for Scotland (GPASS) for the year November 1999 to October 2000 and prescribing patterns for children aged 0–16 years expressed as percentages. A comparison of age specific consultations for asthma, as an example of a common paediatric condition, was also made between two separate general practice data sets, the General Practice Research Database (GRPD) and the continuous morbidity recording (CMR) subset of GPASS. Results Of 214 medicines investigated for unlicensed and off-label prescribing no unlicensed prescribing was identified. Off-label prescribing due to age was most common among younger and older children. The most common reasons for off-label prescriptions were, in order of frequency, lower than recommended dose, higher than recommended dose, below the recommended age, and unlicensed formulation. Age and gender specific consultations for asthma were similar in the two representative databases, GPRD and CMR, both showing disappearance of the male predominance in the teenage years. Conclusions Large primary care data sets available within a unified health care system such as the UK National Health Service (NHS) are likely to be broadly compatible and produce similar results. The prescribing of off-label medicines to children is common in primary care, most commonly due to prescribing out with the recommended dosage regimen. PMID:15948933
Management of first-episode pelvic inflammatory disease in primary care: results from a large UK primary care database.

PubMed

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

2010-10-01

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

PubMed Central

Olier, Ivan; Springate, David A.; Ashcroft, Darren M.; Doran, Tim; Reeves, David; Planner, Claire; Reilly, Siobhan; Kontopantelis, Evangelos

2016-01-01

Background The use of Electronic Health Records databases for medical research has become mainstream. In the UK, increasing use of Primary Care Databases is largely driven by almost complete computerisation and uniform standards within the National Health Service. Electronic Health Records research often begins with the development of a list of clinical codes with which to identify cases with a specific condition. We present a methodology and accompanying Stata and R commands (pcdsearch/Rpcdsearch) to help researchers in this task. We present severe mental illness as an example. Methods We used the Clinical Practice Research Datalink, a UK Primary Care Database in which clinical information is largely organised using Read codes, a hierarchical clinical coding system. Pcdsearch is used to identify potentially relevant clinical codes and/or product codes from word-stubs and code-stubs suggested by clinicians. The returned code-lists are reviewed and codes relevant to the condition of interest are selected. The final code-list is then used to identify patients. Results We identified 270 Read codes linked to SMI and used them to identify cases in the database. We observed that our approach identified cases that would have been missed with a simpler approach using SMI registers defined within the UK Quality and Outcomes Framework. Conclusion We described a framework for researchers of Electronic Health Records databases, for identifying patients with a particular condition or matching certain clinical criteria. The method is invariant to coding system or database and can be used with SNOMED CT, ICD or other medical classification code-lists. PMID:26918439
Surveillance of mother-to-child HIV transmission: socioeconomic and health care coverage indicators.

PubMed

Barcellos, Christovam; Acosta, Lisiane Morelia Weide; Lisboa, Eugenio; Bastos, Francisco Inácio

2009-12-01

To identify clustering areas of infants exposed to HIV during pregnancy and their association with indicators of primary care coverage and socioeconomic condition. Ecological study where the unit of analysis was primary care coverage areas in the city of Porto Alegre, Southern Brazil, in 2003. Geographical Information System and spatial analysis tools were used to describe indicators of primary care coverage areas and socioeconomic condition, and estimate the prevalence of liveborn infants exposed to HIV during pregnancy and delivery. Data was obtained from Brazilian national databases. The association between different indicators was assessed using Spearman's nonparametric test. There was found an association between HIV infection and high birth rates (r=0.22, p<0.01) and lack of prenatal care (r=0.15, p<0.05). The highest HIV infection rates were seen in areas with poor socioeconomic conditions and difficult access to health services (r=0.28, p<0.01). The association found between higher rate of prenatal care among HIV-infected women and adequate immunization coverage (r=0.35, p<0.01) indicates that early detection of HIV infection is effective in those areas with better primary care services. Urban poverty is a strong determinant of mother-to-child HIV transmission but this trend can be fought with health surveillance at the primary care level.
Perceptions of the uses of routine general practice data beyond individual care in England: a qualitative study.

PubMed

Wyatt, David; Cook, Jenny; McKevitt, Christopher

2018-01-08

To investigate how different lay and professional groups perceive and understand the use of routinely collected general practice patient data for research, public health, service evaluation and commissioning. We conducted a multimethod, qualitative study. This entailed participant observation of the design and delivery of a series of deliberative engagement events about a local patient database made of routine primary care data. We also completed semistructured interviews with key professionals involved in the database. Qualitative data were thematically analysed. The research took place in an inner city borough in England. Of the community groups who participated in the six engagement events (111 individual citizens), five were health focused. It was difficult to recruit other types of organisations. Participants supported the uses of the database, but it was unclear how well they understood its scope and purpose. They had concerns about transparency, security and the potential misuse of data. Overall, they were more focused on the need for immediate investment in primary care capacity than data infrastructures to improve future health. The 10 interviewed professionals identified the purpose of the database in different ways, according to their interests. They emphasised the promise of the database as a resource in health research in its own right and in linking it to other datasets. Findings demonstrate positivity to the uses of this local database, but a disconnect between the long-term purposes of the database and participants' short-term priorities for healthcare quality. Varying understandings of the database and the potential for it to be used in multiple different ways in the future cement a need for systematic and routine public engagement to develop and maintain public awareness. Problems recruiting community groups signal a need to consider how we engage wider audiences more effectively. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Perceptions of the uses of routine general practice data beyond individual care in England: a qualitative study

PubMed Central

Cook, Jenny; McKevitt, Christopher

2018-01-01

Objective To investigate how different lay and professional groups perceive and understand the use of routinely collected general practice patient data for research, public health, service evaluation and commissioning. Design, method, participants and setting We conducted a multimethod, qualitative study. This entailed participant observation of the design and delivery of a series of deliberative engagement events about a local patient database made of routine primary care data. We also completed semistructured interviews with key professionals involved in the database. Qualitative data were thematically analysed. The research took place in an inner city borough in England. Results Of the community groups who participated in the six engagement events (111 individual citizens), five were health focused. It was difficult to recruit other types of organisations. Participants supported the uses of the database, but it was unclear how well they understood its scope and purpose. They had concerns about transparency, security and the potential misuse of data. Overall, they were more focused on the need for immediate investment in primary care capacity than data infrastructures to improve future health. The 10 interviewed professionals identified the purpose of the database in different ways, according to their interests. They emphasised the promise of the database as a resource in health research in its own right and in linking it to other datasets. Conclusions Findings demonstrate positivity to the uses of this local database, but a disconnect between the long-term purposes of the database and participants’ short-term priorities for healthcare quality. Varying understandings of the database and the potential for it to be used in multiple different ways in the future cement a need for systematic and routine public engagement to develop and maintain public awareness. Problems recruiting community groups signal a need to consider how we engage wider audiences more effectively. PMID:29317420
Palliative care in the home: a scoping review of study quality, primary outcomes, and thematic component analysis.

PubMed

Hofmeister, Mark; Memedovich, Ally; Dowsett, Laura E; Sevick, Laura; McCarron, Tamara; Spackman, Eldon; Stafinski, Tania; Menon, Devidas; Noseworthy, Tom; Clement, Fiona

2018-03-07

The aim of palliative care is to improve the quality of life of patients and families through the prevention and relief of suffering. Frequently, patients may choose to receive palliative care in the home. The objective of this paper is to summarize the quality and primary outcomes measured within the palliative care in the home literature. This will synthesize the current state of the literature and inform future work. A scoping review was completed using PRISMA guidelines. PubMed, Embase, CINAHL, Web of Science, Cochrane Library, EconLit, PsycINFO, Centre for Reviews and Dissemination, Database of Abstracts of Reviews of Effects, and National Health Service Economic Evaluation Database were searched from inception to August 2016. Inclusion criteria included: 1) care was provided in the "home of the patient" as defined by the study, 2) outcomes were reported, and 3) reported original data. Thematic component analysis was completed to categorize interventions. Fifty-three studies formed the final data set. The literature varied extensively. Five themes were identified: accessibility of healthcare, caregiver support, individualized patient centered care, multidisciplinary care provision, and quality improvement. Primary outcomes were resource use, symptom burden, quality of life, satisfaction, caregiver distress, place of death, cost analysis, or described experiences. The majority of studies were of moderate or unclear quality. There is robust literature of varying quality, assessing different components of palliative care in the home interventions, and measuring different outcomes. To be meaningful to patients, these interventions need to be consistently evaluated with outcomes that matter to patients. Future research could focus on reaching a consensus for outcomes to evaluate palliative care in the home interventions.
Computerized clinical decision support systems for primary preventive care: a decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes.

PubMed

Souza, Nathan M; Sebaldt, Rolf J; Mackay, Jean A; Prorok, Jeanette C; Weise-Kelly, Lorraine; Navarro, Tamara; Wilczynski, Nancy L; Haynes, R Brian

2011-08-03

Computerized clinical decision support systems (CCDSSs) are claimed to improve processes and outcomes of primary preventive care (PPC), but their effects, safety, and acceptance must be confirmed. We updated our previous systematic reviews of CCDSSs and integrated a knowledge translation approach in the process. The objective was to review randomized controlled trials (RCTs) assessing the effects of CCDSSs for PPC on process of care, patient outcomes, harms, and costs. We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews Database, Inspec, and other databases, as well as reference lists through January 2010. We contacted authors to confirm data or provide additional information. We included RCTs that assessed the effect of a CCDSS for PPC on process of care and patient outcomes compared to care provided without a CCDSS. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive. We added 17 new RCTs to our 2005 review for a total of 41 studies. RCT quality improved over time. CCDSSs improved process of care in 25 of 40 (63%) RCTs. Cumulative scientifically strong evidence supports the effectiveness of CCDSSs for screening and management of dyslipidaemia in primary care. There is mixed evidence for effectiveness in screening for cancer and mental health conditions, multiple preventive care activities, vaccination, and other preventive care interventions. Fourteen (34%) trials assessed patient outcomes, and four (29%) reported improvements with the CCDSS. Most trials were not powered to evaluate patient-important outcomes. CCDSS costs and adverse events were reported in only six (15%) and two (5%) trials, respectively. Information on study duration was often missing, limiting our ability to assess sustainability of CCDSS effects. Evidence supports the effectiveness of CCDSSs for screening and treatment of dyslipidaemia in primary care with less consistent evidence for CCDSSs used in screening for cancer and mental health-related conditions, vaccinations, and other preventive care. CCDSS effects on patient outcomes, safety, costs of care, and provider satisfaction remain poorly supported.
Continuing care and long-term substance use outcomes in managed care: early evidence for a primary care-based model.

PubMed

Chi, Felicia W; Parthasarathy, Sujaya; Mertens, Jennifer R; Weisner, Constance M

2011-10-01

How best to provide ongoing services to patients with substance use disorders to sustain long-term recovery is a significant clinical and policy question that has not been adequately addressed. Analyzing nine years of prospective data for 991 adults who entered substance abuse treatment in a private, nonprofit managed care health plan, this study aimed to examine the components of a continuing care model (primary care, specialty substance abuse treatment, and psychiatric services) and their combined effect on outcomes over nine years after treatment entry. In a longitudinal observational study, follow-up measures included self-reported alcohol and drug use, Addiction Severity Index scores, and service utilization data extracted from the health plan databases. Remission, defined as abstinence or nonproblematic use, was the outcome measure. A mixed-effects logistic random intercept model controlling for time and other covariates found that yearly primary care, and specialty care based on need as measured at the prior time point, were positively associated with remission over time. Persons receiving continuing care (defined as having yearly primary care and specialty substance abuse treatment and psychiatric services when needed) had twice the odds of achieving remission at follow-ups (p<.001) as those without. Continuing care that included both primary care and specialty care management to support ongoing monitoring, self-care, and treatment as needed was important for long-term recovery of patients with substance use disorders.
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.
Mentoring new nurse practitioners to accelerate their development as primary care providers: a literature review.

PubMed

Harrington, Susan

2011-04-01

To provide a review of the literature regarding programs for mentoring new nurse practitioners (NPs) to accelerate their development as primary care providers. A search was conducted in PubMed, Ovid, CINAHL, and Cochrane Database of Systematic Reviews. There is currently a critical shortage of primary care providers and an aging population requiring management of chronic medical conditions. Although NPs are trained in health promotion, disease prevention, and medical management and are well equipped to treat patients in primary care, the work can be overwhelming to the novice NP. A mentoring program could help the new NP further develop competencies and capabilities as a provider. However, there is a gap in the literature concerning any mentoring programs for novice NPs. Nonetheless, the literature review has provided a mentoring definition, program models, desired characteristics of nurse mentors, and barriers to mentoring programs. It has also described the benefits, goals and outcomes of a mentoring relationship. These insights from the literature provide a foundation for future mentoring program development. A mentoring program for new NPs working in primary care could accelerate productivity, increase job satisfaction, and provide longevity in the primary care setting. ©2011 The Author(s) Journal compilation ©2011 American Academy of Nurse Practitioners.
Child language interventions in public health: a systematic literature review.

PubMed

De Cesaro, Bruna Campos; Gurgel, Léia Gonçalves; Nunes, Gabriela Pisoni Canedo; Reppold, Caroline Tozzi

2013-01-01

Systematically review the literature on interventions in children's language in primary health care. One searched the electronic databases (January 1980 to March 2013) MEDLINE (accessed by PubMed), Scopus, Lilacs and Scielo. The search terms used were "child language", "primary health care", "randomized controlled trial" and "intervention studies" (in English, Portuguese and Spanish). There were included any randomized controlled trials that addressed the issues child language and primary health care. The analysis was based on the type of language intervention conducted in primary health care. Seven studies were included and used intervention strategies such as interactive video, guidance for parents and group therapy. Individuals of both genders were included in the seven studies. The age of the children participant in the samples of the articles included in this review ranged from zero to 11 years. These seven studies used approaches that included only parents, parents and children or just children. The mainly intervention in language on primary health care, used in randomized controlled trials, involved the use of interactional video. Several professionals, beyond speech and language therapist, been inserted in the language interventions on primary health care, demonstrating the importance of interdisciplinary work. None of the articles mentioned aspects related to hearing. There was scarcity of randomized controlled trials that address on language and public health, either in Brazil or internationally.
Introducing care pathway commissioning to primary dental care: measuring performance.

PubMed

Harris, R; Bridgman, C; Ahmad, M; Bowes, L; Haley, R; Saleem, S; Singh, R; Taylor, S

2011-12-09

Care pathways have been used in a variety of ways: firstly to support quality improvement through standardising clinical processes, but also for secondary purposes, by purchasers of healthcare, to monitor activity and health outcomes and to commission services. This paper focuses on reporting a secondary use of care pathways: to commission and monitor performance of primary dental care services. Findings of a project involving three dental practices implementing a system based on rating patients according to their risk of disease and need for care are outlined. Data from surgery-based clinical databases and interviews from commissioners and providers are reported. The use of both process and outcome key performance indicators in this context is discussed, as well as issues which arise such as attributability of outcome measures and strategic approaches to improving quality of care.
Reliability of intensive care unit admitting and comorbid diagnoses, race, elements of Acute Physiology and Chronic Health Evaluation II score, and predicted probability of mortality in an electronic intensive care unit database.

PubMed

Wenner, Joshua B; Norena, Monica; Khan, Nadia; Palepu, Anita; Ayas, Najib T; Wong, Hubert; Dodek, Peter M

2009-09-01

Although reliability of severity of illness and predicted probability of hospital mortality have been assessed, interrater reliability of the abstraction of primary and other intensive care unit (ICU) admitting diagnoses and underlying comorbidities has not been studied. Patient data from one ICU were originally abstracted and entered into an electronic database by an ICU nurse. A research assistant reabstracted patient demographics, ICU admitting diagnoses and underlying comorbidities, and elements of Acute Physiology and Chronic Health Evaluation II (APACHE II) score from 100 random patients of 474 admitted during 2005 using an identical electronic database. Chamberlain's percent positive agreement was used to compare diagnoses and comorbidities between the 2 data abstractors. A kappa statistic was calculated for demographic variables, Glasgow Coma Score, APACHE II chronic health points, and HIV status. Intraclass correlation was calculated for acute physiology points and predicted probability of hospital mortality. Percent positive agreement for ICU primary and other admitting diagnoses ranged from 0% (primary brain injury) to 71% (sepsis), and for underlying comorbidities, from 40% (coronary artery bypass graft) to 100% (HIV). Agreement as measured by kappa statistic was strong for race (0.81) and age points (0.95), moderate for chronic health points (0.50) and HIV (0.66), and poor for Glasgow Coma Score (0.36). Intraclass correlation showed a moderate-high agreement for acute physiology points (0.88) and predicted probability of hospital mortality (0.71). Reliability for ICU diagnoses and elements of the APACHE II score is related to the objectivity of primary data in the medical charts.
Health benefits of primary care social work for adults with complex health and social needs: a systematic review.

PubMed

McGregor, Jules; Mercer, Stewart W; Harris, Fiona M

2018-01-01

The prevalence of complex health and social needs in primary care patients is growing. Furthermore, recent research suggests that the impact of psychosocial distress on the significantly poorer health outcomes in this population may have been underestimated. The potential of social work in primary care settings has been extensively discussed in both health and social work literature and there is evidence that social work interventions in other settings are particularly effective in addressing psychosocial needs. However, the evidence base for specific improved health outcomes related to primary care social work is minimal. This review aimed to identify and synthesise the available evidence on the health benefits of social work interventions in primary care settings. Nine electronic databases were searched from 1990 to 2015 and seven primary research studies were retrieved. Due to the heterogeneity of studies, a narrative synthesis was conducted. Although there is no definitive evidence for effectiveness, results suggest a promising role for primary care social work interventions in improving health outcomes. These include subjective health measures and self-management of long-term conditions, reducing psychosocial morbidity and barriers to treatment and health maintenance. Although few rigorous study designs were found, the contextual detail and clinical settings of studies provide evidence of the practice applicability of social work intervention. Emerging policy on the integration of health and social care may provide an opportunity to develop this model of care. © 2016 John Wiley & Sons Ltd.
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).
Effective recruitment strategies in primary care research: a systematic review.

PubMed

Ngune, Irene; Jiwa, Moyez; Dadich, Ann; Lotriet, Jaco; Sriram, Deepa

2012-01-01

Patient recruitment in primary care research is often a protracted and frustrating process, affecting project timeframes, budget and the dissemination of research findings. Yet, clear guidance on patient recruitment strategies in primary care research is limited. This paper addresses this issue through a systematic review. Articles were sourced from five academic databases - AustHealth, CINAHL, the Cochrane Methodology Group, EMBASE and PubMed/Medline; grey literature was also sourced from an academic library and the Primary Healthcare Research & Information Service (PHCRIS) website. Two reviewers independently screened the articles using the following criteria: (1) published in English, (2) reported empirical research, (3) focused on interventions designed to increase patient recruitment in primary care settings, and (4) reported patient recruitment in primary care settings. Sixty-six articles met the inclusion criteria. Of these, 23 specifically focused on recruitment strategies and included randomised trials (n = 7), systematic reviews (n = 8) and qualitative studies (n = 8). Of the remaining articles, 30 evaluated recruitment strategies, while 13 addressed the value of recruitment strategies using descriptive statistics and/or qualitative data. Among the 66 articles, primary care chiefly included general practice (n = 30); nursing and allied health services, multiple settings, as well as other community settings (n = 30); and pharmacy (n = 6). Effective recruitment strategies included the involvement of a discipline champion, simple patient eligibility criteria, patient incentives and organisational strategies that reduce practitioner workload. The most effective recruitment in primary care research requires practitioner involvement. The active participation of primary care practitioners in both the design and conduct of research helps to identify strategies that are congruent with the context in which patient care is delivered. This is reported to be the optimal recruitment strategy.
The burden of chickenpox disease in Sweden.

PubMed

Widgren, Katarina; Giesecke, Johan; Lindquist, Lars; Tegnell, Anders

2016-11-10

Chickenpox vaccine is not included in the routine childhood vaccination programme in Sweden. The aim of this study was to estimate the baseline of national chickenpox disease burden, as comprehensive studies, required for an assessment regarding vaccine introduction, are lacking. We used available health care registers and databases; the death register, hospitalisations register, communicable disease notifications database, Stockholm County registers on consultations in specialist and primary care, temporary parental benefit to care for a sick child, and searches on the health care system's website. From each data source, records regarding chickenpox were identified and extracted, either using relevant diagnosis codes (ICD-10) or key words. A descriptive analysis with regards to number of cases and incidence, severity, and seasonality, was carried out covering the time period 2007 to 2013. There were on average 333 patients hospitalised annually due to chickenpox, yielding a hospitalisation rate of 3.56/100,000 person-years. We found a slight male predominance in hospitalised cases. The highest hospitalisation rate was seen in 1 year-olds, whereas the peak in primary care consultations was in 2 year-olds. Nearly a quarter of children had parents who reported absence from work to care for them when sick with chickenpox. The average yearly death rate from chickenpox was 0.034/100,000 person-years. The duration of hospital stay increased with age. The seasonality in number of searches on the health care website corresponded well with hospitalisations and primary care consultations with peaks in spring. This study shows chickenpox death and hospitalisation rates in range with other European countries without routine vaccination. Swedish children fall ill with chickenpox at a very young age. The study provides essential input for future discussions on the introduction of routine chickenpox vaccination in Sweden.

Georeferenced and secure mobile health system for large scale data collection in primary care.

PubMed

Sa, Joao H G; Rebelo, Marina S; Brentani, Alexandra; Grisi, Sandra J F E; Iwaya, Leonardo H; Simplicio, Marcos A; Carvalho, Tereza C M B; Gutierrez, Marco A

2016-10-01

Mobile health consists in applying mobile devices and communication capabilities for expanding the coverage and improving the effectiveness of health care programs. The technology is particularly promising for developing countries, in which health authorities can take advantage of the flourishing mobile market to provide adequate health care to underprivileged communities, especially primary care. In Brazil, the Primary Care Information System (SIAB) receives primary health care data from all regions of the country, creating a rich database for health-related action planning. Family Health Teams (FHTs) collect this data in periodic visits to families enrolled in governmental programs, following an acquisition procedure that involves filling in paper forms. This procedure compromises the quality of the data provided to health care authorities and slows down the decision-making process. To develop a mobile system (GeoHealth) that should address and overcome the aforementioned problems and deploy the proposed solution in a wide underprivileged metropolitan area of a major city in Brazil. The proposed solution comprises three main components: (a) an Application Server, with a database containing family health conditions; and two clients, (b) a Web Browser running visualization tools for management tasks, and (c) a data-gathering device (smartphone) to register and to georeference the family health data. A data security framework was designed to ensure the security of data, which was stored locally and transmitted over public networks. The system was successfully deployed at six primary care units in the city of Sao Paulo, where a total of 28,324 families/96,061 inhabitants are regularly followed up by government health policies. The health conditions observed from the population covered were: diabetes in 3.40%, hypertension (age >40) in 23.87% and tuberculosis in 0.06%. This estimated prevalence has enabled FHTs to set clinical appointments proactively, with the aim of confirming or detecting cases of non-communicable diseases more efficiently, based on real-time information. The proposed system has the potential to improve the efficiency of primary care data collection and analysis. In terms of direct costs, it can be considered a low-cost solution, with an estimated additional monthly cost of U$ 0.040 per inhabitant of the region covered, or approximately U$ 0.106 per person, considering only those currently enrolled in the system. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
A literature review: polypharmacy protocol for primary care.

PubMed

Skinner, Mary

2015-01-01

The purpose of this literature review is to critically evaluate published protocols on polypharmacy in adults ages 65 and older that are currently used in primary care settings that may potentially lead to fewer adverse drug events. A review of OVID, CINAHL, EBSCO, Cochrane Library, Medline, and PubMed databases was completed using the following key words: protocol, guideline, geriatrics, elderly, older adult, polypharmacy, and primary care. Inclusion criteria were: articles in medical, nursing, and pharmacology journals with an intervention, protocol, or guideline addressing polypharmacy that lead to fewer adverse drug events. Qualitative and quantitative studies were included. Exclusion criteria were: publications prior to the year 1992. A gap exists in the literature. No standardized protocol for addressing polypharmacy in the primary care setting was found. Mnemonics, algorithms, clinical practice guidelines, and clinical strategies for addressing polypharmacy in a variety of health care settings were found throughout the literature. Several screening instruments for use in primary care to assess potentially inappropriate prescription of medications in the elderly, such as the Beers Criteria and the STOPP screening tool, were identified. However, these screening instruments were not included in a standardized protocol to manage polypharmacy in primary care. Polypharmacy in the elderly is a critical problem that may result in adverse drug events such as falls, hospitalizations, and increased expenditures for both the patient and the health care system. No standardized protocols to address polypharmacy specific to the primary care setting were identified in this review of the literature. Given the growing population of elderly in this country and the high number of medications they consume, it is critical to focus on the utilization of a standardized protocol to address the potential harm of polypharmacy in the primary care setting and evaluate its effects on patient outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.
Referral interventions from primary to specialist care: a systematic review of international evidence

PubMed Central

Blank, Lindsay; Baxter, Susan; Woods, Helen Buckley; Goyder, Elizabeth; Lee, Andrew; Payne, Nick; Rimmer, Melanie

2014-01-01

Background Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure. Aim To review the international evidence on interventions to manage referral from primary to specialist care. Design and setting Systematic review. Method Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions. Results The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no ‘magic bullet’ to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts. Conclusions To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision. PMID:25452541
A meta-ethnography of organisational culture in primary care medical practice.

PubMed

Grant, Suzanne; Guthrie, Bruce; Entwistle, Vikki; Williams, Brian

2014-01-01

Over the past decade, there has been growing international interest in shaping local organisational cultures in primary healthcare. However, the contextual relevance of extant culture assessment instruments to the primary care context has been questioned. The aim of this paper is to derive a new contextually appropriate understanding of the key dimensions of primary care medical practice organisational culture and their inter-relationship through a synthesis of published qualitative research. A systematic search of six electronic databases followed by a synthesis using techniques of meta-ethnography involving translation and re-interpretation. A total of 16 papers were included in the meta-ethnography from the UK, the USA, Canada, Australia and New Zealand that fell into two related groups: those focused on practice organisational characteristics and narratives of practice individuality; and those focused on sub-practice variation across professional, managerial and administrative lines. It was found that primary care organisational culture was characterised by four key dimensions, i.e. responsiveness, team hierarchy, care philosophy and communication. These dimensions are multi-level and inter-professional in nature, spanning both practice and sub-practice levels. The research contributes to organisational culture theory development. The four new cultural dimensions provide a synthesized conceptual framework for researchers to evaluate and understand primary care cultural and sub-cultural levels. The synthesised cultural dimensions present a framework for practitioners to understand and change organisational culture in primary care teams. The research uses an innovative research methodology to synthesise the existing qualitative research and is one of the first to develop systematically a qualitative conceptual framing of primary care organisational culture.
From theoretical concepts to policies and applied programmes: the landscape of integration of oral health in primary care.

PubMed

Harnagea, Hermina; Lamothe, Lise; Couturier, Yves; Esfandiari, Shahrokh; Voyer, René; Charbonneau, Anne; Emami, Elham

2018-02-15

Despite its importance, the integration of oral health into primary care is still an emerging practice in the field of health care services. This scoping review aims to map the literature and provide a summary on the conceptual frameworks, policies and programs related to this concept. Using the Levac et al. six-stage framework, we performed a systematic search of electronic databases, organizational websites and grey literature from 1978 to April 2016. All relevant original publications with a focus on the integration of oral health into primary care were retrieved. Content analyses were performed to synthesize the results. From a total of 1619 citations, 67 publications were included in the review. Two conceptual frameworks were identified. Policies regarding oral heath integration into primary care were mostly oriented toward common risk factors approach and care coordination processes. In general, oral health integrated care programs were designed in the public health sector and based on partnerships with various private and public health organizations, governmental bodies and academic institutions. These programmes used various strategies to empower oral health integrated care, including building interdisciplinary networks, training non-dental care providers, oral health champion modelling, enabling care linkages and care coordinated process, as well as the use of e-health technologies. The majority of studies on the programs outcomes were descriptive in nature without reporting long-term outcomes. This scoping review provided a comprehensive overview on the concept of integration of oral health in primary care. The findings identified major gaps in reported programs outcomes mainly because of the lack of related research. However, the results could be considered as a first step in the development of health care policies that support collaborative practices and patient-centred care in the field of primary care sector.
Impact of physician distribution policies on primary care practices in rural Quebec.

PubMed

Da Silva, Roxane Borgès; Pineault, Raynald

2012-01-01

Accessibility and continuity of primary health care in rural Canada are inadequate, mainly because of a relative shortage of family physicians. To alleviate the uneven distribution of physicians in rural and urban regions, Quebec has implemented measures associated with 3 types of physician practices in rural areas. The objectives of our study were to describe the practices of these types of physicians in a rural area and to analyze the impact of physician distribution policies aimed at offsetting the lack of resources. Data were drawn from a medical administrative database and included information related to physicians' practices in the rural area of Beauce, Que., in 2007. The practices of permanently settled physicians in rural areas differ from those of physicians who substitute for short periods. Permanently settled physicians offer mostly primary care services, whereas physicians who temporarily substitute devote much of their time to hospital-based practice. Physician distribution policies implemented in Quebec to compensate for the lack of medical resources in rural areas have reduced the deficit in hospital care but not in primary care.
Do female primary care physicians practise preventive care differently from their male colleagues?

PubMed Central

Woodward, C. A.; Hutchison, B. G.; Abelson, J.; Norman, G.

1996-01-01

OBJECTIVE: To assess whether female primary care physicians' reported coverage of patients eligible for certain preventive care strategies differs from male physicians' reported coverage. DESIGN: A mailed survey. SETTING: Primary care practices in southern Ontario. PARTICIPANTS: All primary care physicians who graduated between 1972 and 1988 and practised in a defined geographic area of Ontario were selected from the Canadian Medical Association's physician resource database. Response rate was 50%. MAIN OUTCOME MEASURES: Answers to questions on sociodemographic and practice characteristics, attitudes toward preventive care, and perceptions about preventive care behaviour and practices. RESULTS: In general, reported coverage for Canadian Task Force on the Periodic Health Examination's (CTFPHE) A and B class recommendations was low. However, more female than male physicians reported high coverage of women patients for female-specific preventive care measures (i.e., Pap smears, breast examinations, and mammography) and for blood pressure measurement. Female physicians appeared to question more patients about a greater number of health risks. Often, sex of physician was the most salient factor affecting whether preventive care services thought effective by the CTFPHE were offered. However, when evidence for effectiveness of preventive services was equivocal or lacking, male and female physicians reported similar levels of coverage. CONCLUSION: Female primary care physicians are more likely than their male colleagues to report that their patients eligible for preventive health measures as recommended by the CTFPHE take advantage of these measures. PMID:8969856
Effectiveness of shared care across the interface between primary and specialty care in chronic disease management.

PubMed

Smith, S M; Allwright, S; O'Dowd, T

2007-07-18

Shared care has been used in the management of many chronic conditions with the assumption that it delivers better care than either primary or specialty care alone. It has been defined as the joint participation of primary care physicians and specialty care physicians in the planned delivery of care, informed by an enhanced information exchange over and above routine discharge and referral notices. It has the potential to offer improved quality and coordination of care delivery across the primary-specialty care interface and to improve outcomes for patients. To determine the effectiveness of shared-care health service interventions designed to improve the management of chronic disease across the primary-specialty care interface. We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) Specialised Register (and the database of studies awaiting assessment); Cochrane Central Register of Controlled Trials (CENTRAL); Database of Abstracts of Reviews of Effects (DARE); MEDLINE (from 1966); EMBASE (from 1980) and CINAHL (from 1982). We also searched the reference lists of included studies. Randomised controlled trials, controlled before and after studies and interrupted time series analyses of shared-care interventions for chronic disease management. The participants were primary care providers, specialty care providers and patients. The outcomes included physical health outcomes, mental health outcomes, and psychosocial health outcomes, treatment satisfaction, measures of care delivery including participation in services, delivery of care and prescribing of appropriate medications, and costs of shared care. Three review authors independently assessed studies for eligibility, extracted data and assessed study quality. Twenty studies of shared care interventions for chronic disease management were identified, 19 of which were randomised controlled trials. The majority of studies examined complex multifaceted interventions and were of relatively short duration. The results were mixed. Overall there were no consistent improvements in physical or mental health outcomes, psychosocial outcomes, psychosocial measures including measures of disability and functioning, hospital admissions, default or participation rates, recording of risk factors and satisfaction with treatment. However, there were clear improvements in prescribing in the studies that considered this outcome. The methodological quality of studies varied considerably with only a minority of studies of high-quality design. Cost data were limited and difficult to interpret across studies. This review indicates that there is, at present, insufficient evidence to demonstrate significant benefits from shared care apart from improved prescribing. Methodological shortcomings, particularly inadequate length of follow-up, may partially account for this lack of evidence. This review indicates that there is no evidence to support the widespread introduction of shared care services at present. Future shared-care interventions should only be developed within research settings and with account taken of the complexity of such interventions and the need to carry out longer studies to test the effectiveness and sustainability of shared care over time.
Measuring disease prevalence: a comparison of musculoskeletal disease using four general practice consultation databases

PubMed Central

Jordan, Kelvin; Clarke, Alexandra M; Symmons, Deborah PM; Fleming, Douglas; Porcheret, Mark; Kadam, Umesh T; Croft, Peter

2007-01-01

Background Primary care consultation data are an important source of information on morbidity prevalence. It is not known how reliable such figures are. Aim To compare annual consultation prevalence estimates for musculoskeletal conditions derived from four general practice consultation databases. Design of study Retrospective study of general practice consultation records. Setting Three national general practice consultation databases: i) Fourth Morbidity Statistics from General Practice (MSGP4, 1991/92), ii) Royal College of General Practitioners Weekly Returns Service (RCGP WRS, 2001), and iii) General Practice Research Database (GPRD, 1991 and 2001); and one regional database (Consultations in Primary Care Archive, 2001). Method Age-sex standardised persons consulting annual prevalence rates for musculoskeletal conditions overall, rheumatoid arthritis, osteoarthritis and arthralgia were derived for patients aged 15 years and over. Results GPRD prevalence of any musculoskeletal condition, rheumatoid arthritis and osteoarthritis was lower than that of the other databases. This is likely to be due to GPs not needing to record every consultation made for a chronic condition. MSGP4 gave the highest prevalence for osteoarthritis but low prevalence of arthralgia which reflects encouragement for GPs to use diagnostic rather than symptom codes. Conclusion Considerable variation exists in consultation prevalence estimates for musculoskeletal conditions. Researchers and health service planners should be aware that estimates of disease occurrence based on consultation will be influenced by choice of database. This is likely to be true for other chronic diseases and where alternative symptom labels exist for a disease. RCGP WRS may give the most reliable prevalence figures for musculoskeletal and other chronic diseases. PMID:17244418
Improving Information on Maternal Medication Use by Linking Prescription Data to Congenital Anomaly Registers: A EUROmediCAT Study.

PubMed

de Jonge, Linda; Garne, Ester; Gini, Rosa; Jordan, Susan E; Klungsoyr, Kari; Loane, Maria; Neville, Amanda J; Pierini, Anna; Puccini, Aurora; Thayer, Daniel S; Tucker, David; Vinkel Hansen, Anne; Bakker, Marian K

2015-11-01

Research on associations between medication use during pregnancy and congenital anomalies is significative for assessing the safe use of a medicine in pregnancy. Congenital anomaly (CA) registries do not have optimal information on medicine exposure, in contrast to prescription databases. Linkage of prescription databases to the CA registries is a potentially effective method of obtaining accurate information on medicine use in pregnancies and the risk of congenital anomalies. We linked data from primary care and prescription databases to five European Surveillance of Congenital Anomalies (EUROCAT) CA registries. The linkage was evaluated by looking at linkage rate, characteristics of linked and non-linked cases, first trimester exposure rates for six groups of medicines according to the prescription data and information on medication use registered in the CA databases, and agreement of exposure. Of the 52,619 cases registered in the CA databases, 26,552 could be linked. The linkage rate varied between registries over time and by type of birth. The first trimester exposure rates and the agreements between the databases varied for the different medicine groups. Information on anti-epileptic drugs and insulins and analogue medicine use recorded by CA registries was of good quality. For selective serotonin reuptake inhibitors, anti-asthmatics, antibacterials for systemic use, and gonadotropins and other ovulation stimulants, the recorded information was less complete. Linkage of primary care or prescription databases to CA registries improved the quality of information on maternal use of medicines in pregnancy, especially for medicine groups that are less fully registered in CA registries.
[Factors conditioning primary care services utilization. Empirical evidence and methodological inconsistencies].

PubMed

Sáez, M

2003-01-01

In Spain, the degree and characteristics of primary care services utilization have been the subject of analysis since at least the 1980s. One of the main reasons for this interest is to assess the extent to which utilization matches primary care needs. In fact, the provision of an adequate health service for those who most need it is a generally accepted priority. The evidence shows that individual characteristics, mainly health status, are the factors most closely related to primary care utilization. Other personal characteristics, such as gender and age, could act as modulators of health care need. Some family and/or cultural variables, as well as factors related to the health care professional and institutions, could explain some of the observed variability in primary care services utilization. Socioeconomic variables, such as income, reveal a paradox. From an aggregate perspective, income is the main determinant of utilization as well as of health care expenditure. When data are analyzed for individuals, however, income is not related to primary health utilization. The situation is controversial, with methodological implications and, above all, consequences for the assessment of the efficiency in primary care utilization. Review of the literature reveals certain methodological inconsistencies that could at least partly explain the disparity of the empirical results. Among others, the following flaws can be highlighted: design problems, measurement errors, misspecification, and misleading statistical methods.Some solutions, among others, are quasi-experiments, the use of large administrative databases and of primary data sources (design problems); differentiation between types of utilization and between units of analysis other than consultations, and correction of measurement errors in the explanatory variables (measurement errors); consideration of relevant explanatory variables (misspecification); and the use of multilevel models (statistical methods).
Performance indicators used to assess the quality of primary dental care.

PubMed

González, Grisel Zacca; Klazinga, Niek; ten Asbroek, Guus; Delnoij, Diana M

2006-12-01

An appropriate quality of medical care including dental care should be an objective of every government that aims to improve the oral health of its population. To determine performance indicators that could be used to assess the quality of primary dental care at different levels of a health care system, the sources for data collection and finally, the dimensions of quality measured by these indicators. An explorative study of the international literature was conducted using medical databases, journals and books, and official websites of organisations and associations. This resulted in a set of 57 indicators, which were classified into the following dimensions for each intended user group: For patients: health outcomes and subjective indicators; for professionals: their performance and the rates of success, failure and complications; for health care system managers and policymakers: their resources, finances and health care utilisation. A set of 57 performance indicators were identified to assess the quality of primary dental care at the levels of patients, professionals and the health care system. These indicators could be used by managers and decision-makers at any level of the health care system according to the characteristics of the services.
Health promotion interventions to address climate change using a primary health care approach: a literature review.

PubMed

Walker, Rae; Hassall, John; Chaplin, Sue; Congues, Janet; Bajayo, Rachael; Mason, Wendy

2011-12-01

This project explored the literature in which key concepts in primary health care and health promotion are overtly applied to the problem of climate change. This paper contains a discussion of the literature relevant to health promotion principles and intervention strategies for addressing climate change mitigation and adaptation in the primary health care sector. The concept of primary health care is that used by the World Health Organization, based on the Declaration of Alma Ata and often referred to as comprehensive primary health care to differentiate it from primary medical care. This was a review of literature identified in electronic databases using two sets of search terms. Set A consisted of 'climate change or global warming or greenhouse effect' and set B consisted of 11 key concepts in primary health care and health promotion, for example community resilience, health promotion, social change, food security and economic development. Relevant literature was identified at the intersection of search term A with a term from set B. A search was completed for each set B term. This paper reports a discussion of major categories of health promotion interventions, namely health communication, community building and settings approaches and uses examples drawn from literature on community resilience and summer heat. These interventions are all applicable to the primary health care sector. There is a small literature on health promotion interventions for climate change mitigation and adaptation but it is incomplete and scattered across many sources. An important area for further research is to link the logic of service provision in primary health care to the logic of mitigation and adaptation in a changing environment. Interventions that link the logic must also link diverse services to provide coherent action on local and domestic scales, the scales at which primary health care acts. Another research gap is in regard to institutional change in the primary health care sector. How do the patterns of knowledge, practice and values need to change in the array of organisations that make up comprehensive primary health care?
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
Face-to-face communication between patients and family physicians in Canada: A scoping review.

PubMed

Armas, Alana; Meyer, Samantha B; Corbett, Kitty K; Pearce, Alex R

2018-05-01

Patient-provider communication is critical in primary care. Canada's unique health system, population distribution, and cultural context suggest there is value in addressing the topic in the Canadian context. We conducted a scoping review to synthesize recent Canadian literature to inform practice in primary care settings and identify research agendas for patient-provider communication in Canada. Using Arksey and O'Malley's framework we searched four literature databases: Medline, Web of Science, CINAHL and EMBASE. We extracted 21,932 articles published between 2010 and 2017. A total of 108 articles met the inclusion criteria. The articles were analyzed qualitatively using thematic analysis to identify major themes. Four major themes were identified: information sharing, relationships, health system challenges, and development and use of communication tools. Our review identified a need for Canadian research regarding: communication in primary care with Aboriginal, immigrant, and rural populations; the impact of medical tourism on primary care; and how to improve communication to facilitate continuity of care. Challenges providers face in primary care in Canada include: communicating with linguistically and culturally diverse populations; addressing issues that emerge with the rise of medical tourism; a need for decision aids to improve communication with patients. Copyright © 2017 Elsevier B.V. All rights reserved.
[Standardization of terminology in laboratory medicine I].

PubMed

Yoon, Soo Young; Yoon, Jong Hyun; Min, Won Ki; Lim, Hwan Sub; Song, Junghan; Chae, Seok Lae; Lee, Chang Kyu; Kwon, Jung Ah; Lee, Kap No

2007-04-01

Standardization of medical terminology is essential for data transmission between health-care institutions or clinical laboratories and for maximizing the benefits of information technology. Purpose of our study was to standardize the medical terms used in the clinical laboratory, such as test names, units, terms used in result descriptions, etc. During the first year of the study, we developed a standard database of concept names for laboratory terms, which covered the terms used in government health care centers, their branch offices, and primary health care units. Laboratory terms were collected from the electronic data interchange (EDI) codes from National Health Insurance Corporation (NHIC), Logical Observation Identifier Names and Codes (LOINC) database, community health centers and their branch offices, and clinical laboratories of representative university medical centers. For standard expression, we referred to the English-Korean/ Korean-English medical dictionary of Korean Medical Association and the rules for foreign language translation. Programs for mapping between LOINC DB and EDI code and for translating English to Korean were developed. A Korean standard laboratory terminology database containing six axial concept names such as components, property, time aspect, system (specimen), scale type, and method type was established for 7,508 test observations. Short names and a mapping table for EDI codes and Unified Medical Language System (UMLS) were added. Synonym tables for concept names, words used in the database, and six axial terms were prepared to make it easier to find the standard terminology with common terms used in the field of laboratory medicine. Here we report for the first time a Korean standard laboratory terminology database for test names, result description terms, result units covering most laboratory tests in primary healthcare centers.
Reducing heart disease through the vegetarian diet using primary prevention.

PubMed

Sticher, Megan A; Smith, Christine B; Davidson, Susan

2010-03-01

To evaluate research on the vegetarian diet for its safety, effectiveness in reducing heart disease, special considerations, contraindications, and its association with decreased cardiovascular disease risk. Selected research and evidence-based dietary guidelines found by searching CINAHL, PubMed, Ovid databases, and the World Wide Web. A carefully planned vegetarian diet with adequate supplementation may be effective for primary prevention of heart disease. The vegetarian diet is cost effective, safe, and relatively easy to implement. Improved dietary choices can help improve many chronic conditions. Guidelines for proper nutrition within a vegetarian lifestyle are readily accessible to patients and professionals alike. Referral to a dietitian is an appropriate option in primary care settings.
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
[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.
Use of technology for note taking and therapeutic alliance.

PubMed

Wiarda, Nicholas R; McMinn, Mark R; Peterson, Mary A; Gregor, Joel A

2014-09-01

Is psychotherapeutic alliance helped or harmed by using an iPad or computer during an intake session? Two studies are reported where psychotherapists use one of three different technologies in semistructured initial interviews: paper and pen, iPad, or a computer. The studies were conducted at a Primary Care Clinic and a Community Mental Health Clinic to provide a broader context to account for recent behavioral health integration into medical settings in addition to a traditional psychotherapy setting. The Primary Care Study consisted of 60 participants from a behavioral health service at a primary care clinic. The Community Mental Health Study involved 55 participants from a community mental health clinic in semirural Oregon. No differences were found for the three technologies in either study. Practice and training implications are offered. PsycINFO Database Record (c) 2014 APA, all rights reserved.

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).
Assessing primary care data quality.

PubMed

Lim, Yvonne Mei Fong; Yusof, Maryati; Sivasampu, Sheamini

2018-04-16

Purpose The purpose of this paper is to assess National Medical Care Survey data quality. Design/methodology/approach Data completeness and representativeness were computed for all observations while other data quality measures were assessed using a 10 per cent sample from the National Medical Care Survey database; i.e., 12,569 primary care records from 189 public and private practices were included in the analysis. Findings Data field completion ranged from 69 to 100 per cent. Error rates for data transfer from paper to web-based application varied between 0.5 and 6.1 per cent. Error rates arising from diagnosis and clinical process coding were higher than medication coding. Data fields that involved free text entry were more prone to errors than those involving selection from menus. The authors found that completeness, accuracy, coding reliability and representativeness were generally good, while data timeliness needs to be improved. Research limitations/implications Only data entered into a web-based application were examined. Data omissions and errors in the original questionnaires were not covered. Practical implications Results from this study provided informative and practicable approaches to improve primary health care data completeness and accuracy especially in developing nations where resources are limited. Originality/value Primary care data quality studies in developing nations are limited. Understanding errors and missing data enables researchers and health service administrators to prevent quality-related problems in primary care data.
Elimination of the Out-of-Pocket Charge for Children's Primary Care Visits: An Application of Value-Based Insurance Design.

PubMed

Sepúlveda, Martín-J; Roebuck, M Christopher; Fronstin, Paul; Vidales-Calderon, Pablo; Parikh, Ashish; Rhee, Kyu

2016-08-01

To evaluate the impact of a value-based insurance design for primary care among children. A retrospective analysis of health care claims data on 25 950 children (<18 years of age) was conducted. Individuals were enrolled in a large employer's health plans when zero out-of-pocket cost for primary care physician visits was implemented. A rigorous propensity score matching process was used to generate a control group of equal size from a database of other employer-sponsored insurees. Multivariate difference-in-differences models estimated the effect of zero out-of-pocket cost on 21 health services and cost outcomes 24 months after intervention. Zero out-of-pocket cost for primary care was associated with significant increases (P < .01) in primary care physician visits (+32 per 100 children), as well as decreases in emergency department (-5 per 100 children) and specialist physician visits (-12 per 100 children). The number of prescription drug fills also declined (-20 per 100 children), yet medication adherence for 3 chronic conditions was unaffected. The receipt of well child visits and 4 recommended vaccinations were all significantly (P < .05) greater under the new plan design feature. Employer costs for primary care increased significantly (P < .01) in association with greater utilization ($29 per child), but specialist visit costs declined (-$12 per child) and total health care costs per child did not exhibit a statistically significant increase. This novel application of value-based insurance design warrants broader deployment and assessment of its longer term outcomes. As with recommended preventive services, policymakers should consider exempting primary care from health insurance cost-sharing. Copyright © 2016 Elsevier Inc. All rights reserved.
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).
Personal Characteristics and Experience of Primary Care Predicting Frequent Use of Emergency Department: A Prospective Cohort Study.

PubMed

Hudon, Catherine; Sanche, Steven; Haggerty, Jeannie L

2016-01-01

A small number of patients frequently using the emergency department (ED) account for a disproportionate amount of the total ED workload and are considered using this service inappropriately. The aim of this study was to identify prospectively personal characteristics and experience of organizational and relational dimensions of primary care that predict frequent use of ED. This study was conducted among parallel cohorts of the general population and primary care patients (N = 1,769). The measures were at baseline (T1), 12 (T2) and 24 months (T3): self-administered questionnaire on current health, health behaviours and primary care experience in the previous year. Use of medical services was confirmed using administrative databases. Mixed effect logistic regression modeling identified characteristics predicting frequent ED utilization. A higher likelihood of frequent ED utilization was predicted by lower socioeconomic status, higher disease burden, lower perceived organizational accessibility, higher number of reported healthcare coordination problems and not having a complete annual check-up, above and beyond adjustment for all independent variables. Personal characteristics such as low socioeconomic status and high disease burden as well as experience of organizational dimensions of primary care such as low accessibility, high healthcare coordination problems and low comprehensiveness of care are prospectively associated with frequent ED utilization. Interventions developed to prevent inappropriate ED visits, such as case management for example, should tailor low socioeconomic status and patients with high disease burden and should aim to improve experience of primary care regarding accessibility, coordination and comprehensiveness.
Barriers and facilitators in the integration of oral health into primary care: a scoping review

PubMed Central

Harnagea, Hermina; Couturier, Yves; Shrivastava, Richa; Girard, Felix; Lamothe, Lise; Bedos, Christophe Pierre

2017-01-01

Objective This scoping study has been conducted to map the literature and provide a descriptive synthesis on the barriers and facilitators of the integration of oral health into primary care. Methods Grounded in the Rainbow conceptual model and using the Levac et al six-stage framework, we performed a systematic search of electronic databases, organisational websites and grey literature from 1978 to April 2016. All publications with a focus on the integration of oral health into primary care were included except commentaries and editorials. Thematic analyses were performed to synthesise the results. Results From a total of 1619 citations, 58 publications were included in the review. Barrier-related themes included: lack of political leadership and healthcare policies; implementation challenges; discipline-oriented education; lack of continuity of care and services and patients’ oral healthcare needs. The facilitators of integration were supportive policies and resources allocation, interdisciplinary education, collaborative practices between dental and other healthcare professionals, presence of local strategic leaders and geographical proximity. Discussion and public health implications This work has advanced the knowledge on the barriers and facilitators at each integration domain and level, which may be helpful if the healthcare organisations decide to integrate oral health and dental services into primary care. The scoping review findings could be useful for both dental and medical workforce and allied primary healthcare providers. They could also guide the development of healthcare policies that support collaborative practices and patient-centred care in the field of primary care. PMID:28951405
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.
Nurse practitioner caseload in primary health care: Scoping review.

PubMed

Martin-Misener, Ruth; Kilpatrick, Kelley; Donald, Faith; Bryant-Lukosius, Denise; Rayner, Jennifer; Valaitis, Ruta; Carter, Nancy; Miller, Patricia A; Landry, Véronique; Harbman, Patricia; Charbonneau-Smith, Renee; McKinlay, R James; Ziegler, Erin; Boesveld, Sarah; Lamb, Alyson

2016-10-01

To identify recommendations for determining patient panel/caseload size for nurse practitioners in community-based primary health care settings. Scoping review of the international published and grey literature. The search included electronic databases, international professional and governmental websites, contact with experts, and hand searches of reference lists. Eligible papers had to (a) address caseload or patient panels for nurse practitioners in community-based primary health care settings serving an all-ages population; and (b) be published in English or French between January 2000 and July 2014. Level one testing included title and abstract screening by two team members. Relevant papers were retained for full text review in level two testing, and reviewed by two team members. A third reviewer acted as a tiebreaker. Data were extracted using a structured extraction form by one team member and verified by a second member. Descriptive statistics were estimated. Content analysis was used for qualitative data. We identified 111 peer-reviewed articles and grey literature documents. Most of the papers were published in Canada and the United States after 2010. Current methods to determine panel/caseload size use large administrative databases, provider work hours and the average number of patient visits. Most of the papers addressing the topic of patient panel/caseload size in community-based primary health care were descriptive. The average number of patients seen by nurse practitioners per day varied considerably within and between countries; an average of 9-15 patients per day was common. Patient characteristics (e.g., age, gender) and health conditions (e.g., multiple chronic conditions) appear to influence patient panel/caseload size. Very few studies used validated tools to classify patient acuity levels or disease burden scores. The measurement of productivity and the determination of panel/caseload size is complex. Current metrics may not capture activities relevant to community-based primary health care nurse practitioners. Tools to measure all the components of these role are needed when determining panel/caseload size. Outcomes research is absent in the determination of panel/caseload size. There are few systems in place to track and measure community-based primary health care nurse practitioner activities. The development of such mechanisms is an important next step to assess community-based primary health care nurse practitioner productivity and determine patient panel/caseload size. Decisions about panel/caseload size must take into account the effects of nurse practitioner activities on outcomes of care. Copyright © 2016 Elsevier Ltd. All rights reserved.
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.
Sex differences in health care consumption in Sweden: A register-based cross-sectional study.

PubMed

Osika Friberg, Ingrid; Krantz, Gunilla; Määttä, Sylvia; Järbrink, Krister

2016-05-01

Generally, health care consumption, especially primary care, is greater among women than men. The extent to which this sex difference is explained by reproduction and sex-specific morbidity is unclear. We examined age- and sex-specific health care service utilization and costs in the western region of Sweden. Data were retrieved from a regional health care database of information on total health care consumption in the population. Use of health care resources was divided into the following diagnosis categories: health care associated with reproduction; health care received for sex-specific morbidity; and health care provided for all other conditions. Total per capita cost for health care was 20% higher for women than for men. When adjusted for reproduction and sex-specific morbidity, the cost-difference decreased to 8%. The remaining cost-difference could be explained by women's substantially higher costs for mental and behavioral disorders and diseases of the musculoskeletal system. Women were more likely to receive more accessible, less expensive primary care, while men were more likely to receive specialist inpatient care. The substantially greater use of reproduction-associated care among women, which largely occurs within primary care, might make it easier to also seek health care for other reasons. Efforts to eliminate barriers that prevent men from investing in their health and seeking primary care could reduce future morbidity and costs for specialist care. More studies and appropriate actions are needed to determine why women are overrepresented in mental, behavioral and musculoskeletal disorders. © 2015 the Nordic Societies of Public Health.
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.
Obesity in primary care: a qualitative synthesis of patient and practitioner perspectives on roles and responsibilities.

PubMed

Henderson, Emily

2015-04-01

Obesity is a top-priority global health issue; however, a clear way to address obesity in primary care is not yet in view. To conduct a meta-ethnography of patient and primary care practitioner perspectives of roles and responsibilities in how to address obesity in the UK, to inform evidence-based services that are acceptable to, and appropriate for, patients and practitioners. Qualitative synthesis applying meta-ethnographic methods according to the Noblit and Hare monograph. Database searches in MEDLINE(®), Social Sciences Citation Index(®), CINAHL, and Health Management Information Consortium were limited to 1997-2012 to examine recent perspectives. Full articles of practitioner and/or patient perspectives on obesity services in primary care were reviewed, and included semi-structured or unstructured interviews and focus groups, and participant observations. Nine studies were synthesised with perspectives from patients (n = 105) and practitioners (n = 144). Practitioners believe that patients are responsible for obesity, and that primary care should not help, or is poorly equipped to do so. Patients 'take responsibility' by 'blaming' themselves, but feel that practitioners should demonstrate more leadership. The empowerment of patients to access health services is reliant on the empowerment of practitioners to take an unambiguous position. Primary care has the potential either to perpetuate or counter obesity-related stigma. There needs to be a firm decision as to what role primary care will take in the prevention and treatment of obesity. To remain ambiguous runs the risk of losing patients' confidence and adding to a growing sense of futility. © British Journal of General Practice 2015.
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.
How best to structure interdisciplinary primary care teams: the study protocol for a systematic review with narrative framework synthesis.

PubMed

Wranik, W Dominika; Hayden, Jill A; Price, Sheri; Parker, Robin M N; Haydt, Susan M; Edwards, Jeanette M; Suter, Esther; Katz, Alan; Gambold, Liesl L; Levy, Adrian R

2016-10-04

Western publicly funded health care systems increasingly rely on interdisciplinary teams to support primary care delivery and management of chronic conditions. This knowledge synthesis focuses on what is known in the academic and grey literature about optimal structural characteristics of teams. Its goal is to assess which factors contribute to the effective functioning of interdisciplinary primary care teams and improved health system outcomes, with specific focus on (i) team structure contribution to team process, (ii) team process contribution to primary care goals, and (iii) team structure contribution to primary care goals. The systematic search of academic literature focuses on four chronic conditions and co-morbidities. Within this scope, qualitative and quantitative studies that assess the effects of team characteristics (funding, governance, organization) on care process and patient outcomes will be searched. Electronic databases (Ovid MEDLINE, Embase, CINAHL, PAIS, Web of Science) will be searched systematically. Online web-based searches will be supported by the Grey Matters Tool. Studies will be included, if they report on interdisciplinary primary care in publicly funded Western health systems, and address the relationships between team structure, process, and/or patient outcomes. Studies will be selected in a three-stage screening process (title/abstract/full text) by two independent reviewers in each stage. Study quality will be assessed using the Mixed Methods Assessment Tool. An a priori framework will be applied to data extraction, and a narrative framework approach is used for the synthesis. Using an integrated knowledge translation approach, an electronic decision support tool will be developed for decision makers. It will be searchable along two axes of inquiry: (i) what primary care goals are supported by specific team characteristics and (ii) how should teams be structured to support specific primary care goals? The results of this evidence review will contribute directly to the design of interdisciplinary primary care teams. The optimized design will support the goals of primary care, contributing to the improved health of populations. PROSPERO CRD42016041884.
[The National Database of the Regional Collaborative Rheumatic Centers as a tool for clinical epidemiology and quality assessment in rheumatology].

PubMed

Zink, Angela; Huscher, Dörte; Listing, Joachim

2003-01-01

The national database of the German Collaborative Arthritis Centres is a well-established tool for the observation and assessment of health care delivery to patients with rheumatic diseases in Germany. The discussion of variations in treatment practices contributes to the internal quality assessment in the participating arthritis centres. This documentation has shown deficits in primary health care including late referral to a rheumatologist, undertreatment with disease-modifying drugs and complementary therapies. In rheumatology, there is a trend towards early, intensive medical treatment including combination therapy. The frequency and length of inpatient hospital and rehabilitation treatments is decreasing, while active physiotherapy in outpatient care has been increased. Specific deficits have been identified concerning the provision of occupational therapy services and patient education.
Health needs of prisoners in England and Wales: the implications for prison healthcare of gender, age and ethnicity.

PubMed

Harris, Francesca; Hek, Gill; Condon, Louise

2007-01-01

This paper aims to provide evidence of the healthcare needs of prisoners in relation to gender, age and ethnicity, drawing from a larger systematic overview of the policy and research literature concerning primary care nursing in prisons in England and Wales. The literature overview shaped the initial stages of a research project funded by the Department of Health to examine the views and perspectives of prisoners and nurses working in prisons, and to identify good primary care nursing in the prison environment. At total of 17 databases were searched using search terms related to primary healthcare in prisons (health, nurs*, primary care, healthcare, family medicine, prison*, offender*, inmate*) with terms truncated where possible in the different databases. Following this, a sifting phase was employed using inclusion/exclusion criteria to narrow and focus the literature perceived as relevant to the research questions. All papers were critically appraised for quality using standardised tools. Findings from the literature overview show that prisoners are more likely to have suffered some form of social exclusion compared to the rest of society, and there are significantly greater degrees of mental health problems, substance abuse and worse physical health in prisoners than in the general population. Women, young offenders, older prisoners and those from minority ethnic groups have distinct health needs compared to the prison population taken as a whole, with implications for the delivery of prison healthcare, and how these needs are met effectively and appropriately.
Understanding the treatment of attention deficit hyperactivity disorder in newly diagnosed adult patients in general practice: a UK database study

PubMed Central

Bushe, Christopher; Wilson, Bernard; Televantou, Foula; Belger, Mark; Watson, Louise

2015-01-01

Background Adult attention deficit hyperactivity disorder (ADHD) has been largely ignored in psychiatric and general practice guidance until recently. Adult ADHD has a high social and medical burden, but health care is not well described in the UK. The main study objective was to evaluate a primary care adult ADHD population in terms of prescribing and health care contact rates. Methods This was a retrospective observational study using data from the Clinical Practice Research Database from January 1, 2002 to July 31, 2011. Adult patients with an incident ADHD diagnosis or ADHD medication were identified as having been free of ADHD medication or diagnoses in the previous 2 years. Patients were followed for 12–24 months after diagnosis. Results Of the 663 patients with ADHD in the cohort, 54.1% were prescribed ADHD medication during the observation period. During the first 6 months, 34.2% of patients initiated methylphenidates and 14.0% atomoxetine. In total, 36.3% patients were referred to secondary care psychiatry during observation, with the remaining population (63.7%) never having a referral. Most of the referrals were before diagnosis in primary care. At the end of the observation period, 16.2% of patients were on antipsychotics, 17.3% hypnotics, and 34.8% antidepressants or anxiolytics; however, some patients appeared to be prescribed antipsychotic or antidepressant medications even if they did not have an observable diagnosis in their records. Health care contact rates (general practitioner or hospital) increased by 39.2% post-diagnosis (incidence rate ratio: 1.39; 95% confidence interval: 1.32, 1.47), which may be related to the need for medication monitoring and titration. Conclusion This study has shown in primary care that there is relatively low use of ADHD medication, low referrals into secondary care, high rates of usage of psychiatric non-ADHD medications for different indications, and an increasing burden in terms of health care contacts in adult ADHD patients post-diagnosis. PMID:27774030
Timely response to secure messages from primary care patients.

PubMed

Rohrer, James E; North, Frederick; Angstman, Kurt B; Oberhelman, Sara S; Meunier, Matthew R

2013-01-01

To assess delays in response to patient secure e-mail messages in primary care. Secure electronic messages are initiated by primary care patients. Timely response is necessary for patient safety and quality. A database of secure messages. A random sample of 353 secure electronic messages initiated by primary care patients treated in 4 clinics. Message not opened after 12 hours or messages not responded to after 36 hours. A total of 8.5% of electronic messages were not opened within 12 hours, and 17.6% did not receive a response in 36 hours. Clinic location, being a clinic employee, and patient sex were not related to delays. Patients older than 50 years were more likely to receive a delayed response (25.7% delayed, P = .013). The risk of both kinds of delays was higher on weekends (P < .001 for both). The e-mail message system resulted in high rates of delayed response. Delays were concentrated on weekends (Friday-Sunday). Reducing delayed responses may require automatic rerouting of messages to message centers staffed 24-7 or other mechanisms to manage this after-hours work flow.
A review of instruments to measure interprofessional team-based primary care.

PubMed

Shoemaker, Sarah J; Parchman, Michael L; Fuda, Kathleen Kerwin; Schaefer, Judith; Levin, Jessica; Hunt, Meaghan; Ricciardi, Richard

2016-07-01

Interprofessional team-based care is increasingly regarded as an important feature of delivery systems redesigned to provide more efficient and higher quality care, including primary care. Measurement of the functioning of such teams might enable improvement of team effectiveness and could facilitate research on team-based primary care. Our aims were to develop a conceptual framework of high-functioning primary care teams to identify and review instruments that measure the constructs identified in the framework, and to create a searchable, web-based atlas of such instruments (available at: http://primarycaremeasures.ahrq.gov/team-based-care/ ). Our conceptual framework was developed from existing frameworks, the teamwork literature, and expert input. The framework is based on an Input-Mediator-Output model and includes 12 constructs to which we mapped both instruments as a whole, and individual instrument items. Instruments were also reviewed for relevance to measuring team-based care, and characterized. Instruments were identified from peer-reviewed and grey literature, measure databases, and expert input. From nearly 200 instruments initially identified, we found 48 to be relevant to measuring team-based primary care. The majority of instruments were surveys (n = 44), and the remainder (n = 4) were observational checklists. Most instruments had been developed/tested in healthcare settings (n = 30) and addressed multiple constructs, most commonly communication (n = 42), heedful interrelating (n = 42), respectful interactions (n = 40), and shared explicit goals (n = 37). The majority of instruments had some reliability testing (n = 39) and over half included validity testing (n = 29). Currently available instruments offer promise to researchers and practitioners to assess teams' performance, but additional work is needed to adapt these instruments for primary care settings.
The Cardiovascular Health in Ambulatory Care Research Team performance indicators for the primary prevention of cardiovascular disease: a modified Delphi panel study.

PubMed

Tu, Jack V; Maclagan, Laura C; Ko, Dennis T; Atzema, Clare L; Booth, Gillian L; Johnston, Sharon; Tu, Karen; Lee, Douglas S; Bierman, Arlene; Hall, Ruth; Bhatia, R Sacha; Gershon, Andrea S; Tobe, Sheldon W; Sanmartin, Claudia; Liu, Peter; Chu, Anna

2017-04-25

High-quality ambulatory care can reduce cardiovascular disease risk, but important gaps exist in the provision of cardiovascular preventive care. We sought to develop a set of key performance indicators that can be used to measure and improve cardiovascular care in the primary care setting. As part of the Cardiovascular Health in Ambulatory Care Research Team initiative, we established a 14-member multidisciplinary expert panel to develop a set of indicators for measuring primary prevention performance in ambulatory cardiovascular care. We used a 2-stage modified Delphi panel process to rate potential indicators, which were identified from the literature and national cardiovascular organizations. The top-rated indicators were pilot tested to determine their measurement feasibility with the use of data routinely collected in the Canadian health care system. A set of 28 indicators of primary prevention performance were identified, which were grouped into 5 domains: risk factor prevalence, screening, management, intermediate outcomes and long-term outcomes. The indicators reflect the major cardiovascular risk factors including smoking, obesity, hypertension, diabetes, dyslipidemia and atrial fibrillation. All indicators were determined to be amenable to measurement with the use of population-based administrative (physician claims, hospital admission, laboratory, medication), survey or electronic medical record databases. The Cardiovascular Health in Ambulatory Care Research Team indicators of primary prevention performance provide a framework for the measurement of cardiovascular primary prevention efforts in Canada. The indicators may be used by clinicians, researchers and policy-makers interested in measuring and improving the prevention of cardiovascular disease in ambulatory care settings. Copyright 2017, Joule Inc. or its licensors.

Health System Features That Enhance Access to Comprehensive Primary Care for Women Living with HIV in High-Income Settings: A Systematic Mixed Studies Review.

PubMed

O'Brien, Nadia; Hong, Quan Nha; Law, Susan; Massoud, Sarah; Carter, Allison; Kaida, Angela; Loutfy, Mona; Cox, Joseph; Andersson, Neil; de Pokomandy, Alexandra

2018-04-01

Women living with HIV in high-income settings continue to experience modifiable barriers to care. We sought to determine the features of care that facilitate access to comprehensive primary care, inclusive of HIV, comorbidity, and sexual and reproductive healthcare. Using a systematic mixed studies review design, we reviewed qualitative, mixed methods, and quantitative studies identified in Ovid MEDLINE, EMBASE, and CINAHL databases (January 2000 to August 2017). Eligibility criteria included women living with HIV; high-income countries; primary care; and healthcare accessibility. We performed a thematic synthesis using NVivo. After screening 3466 records, we retained 44 articles and identified 13 themes. Drawing on a social-ecological framework on engagement in HIV care, we situated the themes across three levels of the healthcare system: care providers, clinical care environments, and social and institutional factors. At the care provider level, features enhancing access to comprehensive primary care included positive patient-provider relationships and availability of peer support, case managers, and/or nurse navigators. Within clinical care environments, facilitators to care were appointment reminder systems, nonidentifying clinic signs, women and family spaces, transportation services, and coordination of care to meet women's HIV, comorbidity, and sexual and reproductive healthcare needs. Finally, social and institutional factors included healthcare insurance, patient and physician education, and dispelling HIV-related stigma. This review highlights several features of care that are particularly relevant to the care-seeking experience of women living with HIV. Improving their health through comprehensive care requires a variety of strategies at the provider, clinic, and greater social and institutional levels.
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.
Adapting a large database of point of care summarized guidelines: a process description.

PubMed

Delvaux, Nicolas; Van de Velde, Stijn; Aertgeerts, Bert; Goossens, Martine; Fauquert, Benjamin; Kunnamo, Ilka; Van Royen, Paul

2017-02-01

Questions posed at the point of care (POC) can be answered using POC summarized guidelines. To implement a national POC information resource, we subscribed to a large database of POC summarized guidelines to complement locally available guidelines. Our challenge was in developing a sustainable strategy for adapting almost 1000 summarized guidelines. The aim of this paper was to describe our process for adapting a database of POC summarized guidelines. An adaptation process based on the ADAPTE framework was tailored to be used by a heterogeneous group of participants. Guidelines were assessed on content and on applicability to the Belgian context. To improve efficiency, we chose to first aim our efforts towards those guidelines most important to primary care doctors. Over a period of 3 years, we screened about 80% of 1000 international summarized guidelines. For those guidelines identified as most important for primary care doctors, we noted that in about half of the cases, remarks were made concerning content. On the other hand, at least two-thirds of all screened guidelines required no changes when evaluating their local usability. Adapting a large body of POC summarized guidelines using a formal adaptation process is possible, even when faced with limited resources. This can be done by creating an efficient and collaborative effort and ensuring user-friendly procedures. Our experiences show that even though in most cases guidelines can be adopted without adaptations, careful review of guidelines developed in a different context remains necessary. Streamlining international efforts in adapting international POC information resources and adopting similar adaptation processes may lessen duplication efforts and prove more cost-effective. © 2015 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.
Use of mental health care for nonpsychotic conditions by immigrants in different admission classes and by refugees in Ontario, Canada.

PubMed

Durbin, Anna; Lin, Elizabeth; Moineddin, Rahim; Steele, Leah S; Glazier, Richard H

2014-01-01

Most Canadian newcomers are admitted in the economic, family, or refugee class, each of which has its own selection criteria and experiences. Evidence has shown various risks for mental health disorders across admission classes, but the respective service-use patterns for people in these classes are unknown. In this study, we compared service use for nonpsychotic mental health disorders by newcomers in various admission classes with that of long-term residents (i.e., Canadian-born persons or immigrants before 1985) in urban Ontario. In this population-based matched cross-sectional study, we linked health service databases to the Ontario portion of the Citizenship and Immigration Canada database. Outcomes were mental health visits to primary care physicians, mental health visits to psychiatrists, and emergency department visits or hospital admissions. We measured service use for recent immigrants (those who arrived in Ontario between 2002 and 2007; n = 359 673). We compared service use by immigrants in each admission class during the first 5 years in Canada with use by age- and sex-matched long-term residents. We measured likelihood of access to each service and intensity of use of each service using conditional logistic regression and negative binomial models. Economic and family class newcomers were less likely than long-term residents to use primary mental health care. The use of primary mental health care by female refugees did not differ from that of matched long-term residents, but use of such care by male refugees was higher (odds ratio 1.14, 95% confidence interval 1.09-1.19). Immigrants in all admission classes were less likely to use psychiatric services and hospital services for mental health care. Exceptions were men in the economic and family classes, whose intensity of hospital visits was similar to that of matched long-term residents. Immigrants in all admission classes generally used less care for nonpsychotic disorders than longterm residents, although male refugees used more primary care. Future research should examine how mental health needs align with service use, particularly for more vulnerable groups such as refugees.
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.
To what extent does sociodemographic composition of the neighbourhood explain regional differences in demand of primary out-of-hours care: a multilevel study.

PubMed

Jansen, Tessa; Zwaanswijk, Marieke; Hek, Karin; de Bakker, Dinny

2015-05-06

In the Netherlands, primary out-of-hours (OOH) care is provided by large scale General Practitioner (GP) cooperatives. GP cooperatives can be contacted by patients living in the area surrounding the GP cooperative (catchment area) at hours when the patient's own general practice is closed. The frequency of primary OOH care use substantially differs between GP cooperative catchment areas. To enable a better match between supply and demand of OOH services, understanding of the factors associated with primary OOH care use is essential. The present study evaluated the contribution of sociodemographic composition of the neighbourhood in explaining differences in primary OOH care use between GP cooperative catchment areas. Data about patients' contacts with primary OOH services (n = 1,668,047) were derived from routine electronic health records of 21 GP cooperatives participating in the NIVEL Primary Care Database in 2012. The study sample is representative for the Dutch population (for age and gender). Data were matched with sociodemographic characteristics (e.g. gender, age, low-income status, degree of urbanisation) on postcode level. Multilevel linear regression models included postcode level (first level), nested within GP cooperative catchment areas (second level). We investigated whether contacts in primary OOH care were associated with neighbourhood sociodemographic characteristics. The demand of primary OOH care was significantly higher in neighbourhoods with more women, low-income households, non-Western immigrants, neighbourhoods with a higher degree of urbanisation, and low neighbourhood socioeconomic status. Conversely, lower demand was associated with neighbourhoods with more 5 to 24 year old inhabitants. Sociodemographic neighbourhood characteristics explained a large part of the variation between GP cooperatives (R-squared ranging from 8% to 52%). Nevertheless, the multilevel models also showed that a considerable amount of variation in demand between GP cooperatives remained unexplained by sociodemographic characteristics, particularly regarding high-urgency contacts. Although part of the variation between GP cooperatives could not be attributed to neighbourhood characteristics, the sociodemographic composition of the neighbourhood is a fair predictor of the demand of primary OOH care. Accordingly, this study provides a useful starting point for an improved planning of the supply of primary OOH care.
Correlation between patients' reasons for encounters/health problems and population density in Japan: a systematic review of observational studies coded by the International Classification of Health Problems in Primary Care (ICHPPC) and the International Classification of Primary care (ICPC).

PubMed

Kaneko, Makoto; Ohta, Ryuichi; Nago, Naoki; Fukushi, Motoharu; Matsushima, Masato

2017-09-13

The Japanese health care system has yet to establish structured training for primary care physicians; therefore, physicians who received an internal medicine based training program continue to play a principal role in the primary care setting. To promote the development of a more efficient primary health care system, the assessment of its current status in regard to the spectrum of patients' reasons for encounters (RFEs) and health problems is an important step. Recognizing the proportions of patients' RFEs and health problems, which are not generally covered by an internist, can provide valuable information to promote the development of a primary care physician-centered system. We conducted a systematic review in which we searched six databases (PubMed, the Cochrane Library, Google Scholar, Ichushi-Web, JDreamIII and CiNii) for observational studies in Japan coded by International Classification of Health Problems in Primary Care (ICHPPC) and International Classification of Primary Care (ICPC) up to March 2015. We employed population density as index of accessibility. We calculated Spearman's rank correlation coefficient to examine the correlation between the proportion of "non-internal medicine-related" RFEs and health problems in each study area in consideration of the population density. We found 17 studies with diverse designs and settings. Among these studies, "non-internal medicine-related" RFEs, which was not thought to be covered by internists, ranged from about 4% to 40%. In addition, "non-internal medicine-related" health problems ranged from about 10% to 40%. However, no significant correlation was found between population density and the proportion of "non-internal medicine-related" RFEs and health problems. This is the first systematic review on RFEs and health problems coded by ICHPPC and ICPC undertaken to reveal the diversity of health problems in Japanese primary care. These results suggest that primary care physicians in some rural areas of Japan need to be able to deal with "non-internal-medicine-related" RFEs and health problems, and that curriculum including practical non-internal medicine-related training is likely to be important.
Protocol for determining primary healthcare practice characteristics, models of practice and patient accessibility using an exploratory census survey with linkage to administrative data in Nova Scotia, Canada.

PubMed

Marshall, Emily Gard; Gibson, Richard J; Lawson, Beverley; Burge, Frederick

2017-03-16

There is little evidence on how primary care providers (PCPs) model their practices in Nova Scotia (NS), Canada, what services they offer or what accessibility is like for the average patient. This study will create a database of all family physicians and primary healthcare nurse practitioners in NS, including information about accessibility and the model of care in which they practice, and will link the survey data to administrative health databases. 3 census surveys of all family physicians, primary care nurse practitioners (ie, PCPs) and their practices in NS will be conducted. The first will be a telephone survey conducted during typical daytime business hours. At each practice, the person answering the telephone will be asked questions about the practice's accessibility and model of care. The second will be a telephone survey conducted after typical daytime business hours to determine what out-of-office services PCP practices offer their patients. The final will be a tailored fax survey that will collect information that could not be obtained in the first 2 surveys plus new information on scope of practice, practice model and willingness to participate in research. Survey data will be linked with billing data from administrative health databases. Multivariate regression analysis will be employed to assess whether access and availability outcome variables are associated with PCP and model of practice characteristics. Negative binomial regression analysis will be employed to assess the association between independent variables from the survey data and health system use outcomes from administrative data. This study has received ethical approval from the Nova Scotia Health Authority and the Health Data Nova Scotia Data Access Committee. Dissemination approached will include stakeholder engagement at local and national levels, conference presentations, peer-reviewed publications and a public website. 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/.
Provision of Patient-Centered Transgender Care.

PubMed

Selix, Nancy W; Rowniak, Stefan

2016-11-01

Transgender individuals have unique health care needs and experience health disparities. There is an increased need for transgender health care services and primary care for this underserved population. However, provision of appropriate health care services for transgender persons requires cultural competency and skill on the part of the health care provider, and providers need specific skills to address the needs of this population. A review of the literature was performed by accessing CINAHL, PsycINFO, and PubMed databases. Pertinent research was extracted and reviewed for relevance. References in these publications were reviewed to identify additional publications that address primary prevention, secondary prevention, and tertiary care of transgender individuals. Articles that include prevention, screening, and treatment of health problems of transgender persons were identified. Research on the health needs of the transgender population is limited. Whenever available, research findings that address this unique population should be incorporated into clinical practice. When research evidence is not available to address the unique needs of transgender individuals, research and clinical care guidelines from the general population may be applied for health screening and maintenance. This article provides information about primary care services for transgender individuals and seeks to improve awareness of the health disparities this underserved population experiences. Simple solutions to modify clinical settings to enhance care are provided. © 2016 by the American College of Nurse-Midwives.
TPMG Northern California appointments and advice call center.

PubMed

Conolly, Patricia; Levine, Leslie; Amaral, Debra J; Fireman, Bruce H; Driscoll, Tom

2005-08-01

Kaiser Permanente (KP) has been developing its use of call centers as a way to provide an expansive set of healthcare services to KP members efficiently and cost effectively. Since 1995, when The Permanente Medical Group (TPMG) began to consolidate primary care phone services into three physical call centers, the TPMG Appointments and Advice Call Center (AACC) has become the "front office" for primary care services across approximately 89% of Northern California. The AACC provides primary care phone service for approximately 3 million Kaiser Foundation Health Plan members in Northern California and responds to approximately 1 million calls per month across the three AACC sites. A database records each caller's identity as well as the day, time, and duration of each call; reason for calling; services provided to callers as a result of calls; and clinical outcomes of calls. We here summarize this information for the period 2000 through 2003.
What is the actual epidemiology of familial hypercholesterolemia in Italy? Evidence from a National Primary Care Database.

PubMed

Guglielmi, Valeria; Bellia, Alfonso; Pecchioli, Serena; Medea, Gerardo; Parretti, Damiano; Lauro, Davide; Sbraccia, Paolo; Federici, Massimo; Cricelli, Iacopo; Cricelli, Claudio; Lapi, Francesco

2016-11-15

There are some inconsistencies on prevalence estimates of familial hypercholesterolemia (FH) in general population across Europe due to variable application of its diagnostic criteria. We aimed to investigate the FH epidemiology in Italy applying the Dutch Lipid Clinical Network (DLCN) score, and two alternative diagnostic algorithms to a primary care database. We performed a retrospective population-based study using the Health Search IMS Health Longitudinal Patient Database (HSD) and including active (alive and currently registered with their general practitioners (GPs)) patients on December 31, 2014. Cases of FH were identified by applying DLCN score. Two further algorithms, based on either ICD9CM coding for FH or some clinical items adopted by the DLCN, were tested towards DLCN itself as gold standard. We estimated a prevalence of 0.01% for "definite" and 0.18% for "definite" plus "probable" cases as per the DLCN. Algorithms 1 and 2 reported a FH prevalence of 0.9 and 0.13%, respectively. Both algorithms resulted in consistent specificity (1: 99.10%; 2: 99.9%) towards DLCN, but Algorithm 2 considerably better identified true positive (sensitivity=85.90%) than Algorithm 1 (sensitivity=10.10%). The application of DLCN or valid diagnostic alternatives in the Italian primary care setting provides estimates of FH prevalence consistent with those reported in other screening studies in Caucasian population. These diagnostic criteria should be therefore fostered among GPs. In the perspective of FH new therapeutic options, the epidemiological picture of FH is even more relevant to foresee the costs and to plan affordable reimbursement programs in Italy. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Evolution of primary care databases in UK: a scientometric analysis of research output.

PubMed

Vezyridis, Paraskevas; Timmons, Stephen

2016-10-11

To identify publication and citation trends, most productive institutions and countries, top journals, most cited articles and authorship networks from articles that used and analysed data from primary care databases (CPRD, THIN, QResearch) of pseudonymised electronic health records (EHRs) in UK. Descriptive statistics and scientometric tools were used to analyse a SCOPUS data set of 1891 articles. Open access software was used to extract networks from the data set (Table2Net), visualise and analyse coauthorship networks of scholars and countries (Gephi) and density maps (VOSviewer) of research topics co-occurrence and journal cocitation. Research output increased overall at a yearly rate of 18.65%. While medicine is the main field of research, studies in more specialised areas include biochemistry and pharmacology. Researchers from UK, USA and Spanish institutions have published the most papers. Most of the journals that publish this type of research and most cited papers come from UK and USA. Authorship varied between 3 and 6 authors. Keyword analyses show that smoking, diabetes, cardiovascular diseases and mental illnesses, as well as medication that can treat such medical conditions, such as non-steroid anti-inflammatory agents, insulin and antidepressants constitute the main topics of research. Coauthorship network analyses show that lead scientists, directors or founders of these databases are, to various degrees, at the centre of clusters in this scientific community. There is a considerable increase of publications in primary care research from EHRs. The UK has been well placed at the centre of an expanding global scientific community, facilitating international collaborations and bringing together international expertise in medicine, biochemical and pharmaceutical research. 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/.
Effect of the Economic Recession on Primary Care Access for the Homeless.

PubMed

White, Brandi M; Jones, Walter J; Moran, William P; Simpson, Kit N

2016-01-01

Primary care access (PCA) for the homeless can prove challenging, especially during periods of economic distress. In the United States, the most recent recession may have presented additional barriers to accessing care. Limited safety-net resources traditionally used by the homeless may have also been used by the non-homeless, resulting in delays in seeking treatment for the homeless. Using hospitalizations for ambulatory care sensitivity (ACS) conditions as a proxy measure for PCA, this study investigated the recession's impact on PCA for the homeless and non-homeless in four states. The State Inpatient Databases were used to identify ACS admissions. Findings from this study indicate the recession was a barrier to PCA for homeless people who were uninsured. Ensuring that economically-disadvantaged populations have the ability to obtain insurance coverage is crucial to facilitating PCA. With targeted outreach efforts, the Affordable Care Act provides an opportunity for expanding coverage to the homeless.
Direct observation of weight-related communication in primary care: a systematic review.

PubMed

McHale, Calum T; Laidlaw, Anita H; Cecil, Joanne E

2016-08-01

Primary care is ideally placed to play an effective role in patient weight management; however, patient weight is seldom discussed in this context. A synthesis of studies that directly observe weight discussion in primary care is required to more comprehensively understand and improve primary care weight-related communication. To systematically identify and examine primary care observational research that investigates weight-related communication and its relationship to patient weight outcomes. A systematic review of literature published up to August 2015, using seven electronic databases (including MEDLINE, Scopus and PsycINFO), was conducted using search terms such as overweight, obese and/or doctor-patient communication. Twenty papers were included in the final review. Communication analysis focused predominantly on 'practitioner' use of specific patient-centred communication. Practitioner use of motivational interviewing was associated with improved patient weight-related outcomes, including patient weight loss and increased patient readiness to lose weight; however, few studies measured patient weight-related outcomes. Studies directly observing weight-related communication in primary care are scarce and limited by a lack of focus on patient communication and patient weight-related outcomes. Future research should measure practitioner and patient communications during weight discussion and their impact on patient weight-related outcomes. This knowledge may inform the development of a communication intervention to assist practitioners to more effectively discuss weight with their overweight and/or obese patients. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
The ALS patient care database: goals, design, and early results. ALS C.A.R.E. Study Group.

PubMed

Miller, R G; Anderson, F A; Bradley, W G; Brooks, B R; Mitsumoto, H; Munsat, T L; Ringel, S P

2000-01-11

The ALS Patient Care Database was created to improve the quality of care for patients with ALS by 1) providing neurologists with data to evaluate and improve their practices, 2) publishing data on temporal trends in the care of patients with ALS, and 3) developing hypotheses to be tested during formal clinical trials. Substantial variations exist in managing ALS, but there has been no North American database to measure outcomes in ALS until now. This observational database is open to all neurologists practicing in North America, who are encouraged to enroll both incident and prevalent ALS patients. Longitudinal data are collected at intervals of 3 to 6 months by using standard data collection instruments. Forms are submitted to a central data coordinating center, which mails quarterly reports to participating neurologists. Beginning in September 1996 through November 30, 1998, 1,857 patients were enrolled at 83 clinical sites. On enrollment, patients had a mean age of 58.6 years +/-12.9 (SD) years (range, 20.1 to 95.1 years), 92% were white, and 61% were men. The mean interval between onset of symptoms and diagnosis was 1.2+/-1.6 years (range, 0 to 31.9 years). Riluzole was the most frequently used disease-specific therapy (48%). Physical therapy was the most common nonpharmacologic intervention (45%). The primary caregiver was generally the spouse (77%). Advance directives were in place at the time of death for 70% of 213 enrolled patients who were reported to have died. The ALS Patient Care Database appears to provide valuable data on physician practices and patient-focused outcomes in ALS.
The limitations of some European healthcare databases for monitoring the effectiveness of pregnancy prevention programmes as risk minimisation measures.

PubMed

Charlton, R A; Bettoli, V; Bos, H J; Engeland, A; Garne, E; Gini, R; Hansen, A V; de Jong-van den Berg, L T W; Jordan, S; Klungsøyr, K; Neville, A J; Pierini, A; Puccini, A; Sinclair, M; Thayer, D; Dolk, H

2018-04-01

Pregnancy prevention programmes (PPPs) exist for some medicines known to be highly teratogenic. It is increasingly recognised that the impact of these risk minimisation measures requires periodic evaluation. This study aimed to assess the extent to which some of the data needed to monitor the effectiveness of PPPs may be present in European healthcare databases. An inventory was completed for databases contributing to EUROmediCAT capturing pregnancy and prescription data in Denmark, Norway, the Netherlands, Italy (Tuscany/Emilia Romagna), Wales and the rest of the UK, to determine the extent of data collected that could be used to evaluate the impact of PPPs. Data availability varied between databases. All databases could be used to identify the frequency and duration of prescriptions to women of childbearing age from primary care, but there were specific issues with availability of data from secondary care and private care. To estimate the frequency of exposed pregnancies, all databases could be linked to pregnancy data, but the accuracy of timing of the start of pregnancy was variable, and data on pregnancies ending in induced abortions were often not available. Data availability on contraception to estimate compliance with contraception requirements was variable and no data were available on pregnancy tests. Current electronic healthcare databases do not contain all the data necessary to fully monitor the effectiveness of PPP implementation, and thus, special data collection measures need to be instituted.
Pharmacoepidemiology resources in Ireland-an introduction to pharmacy claims data.

PubMed

Sinnott, Sarah-Jo; Bennett, Kathleen; Cahir, Caitriona

2017-11-01

Administrative health data, such as pharmacy claims data, present a valuable resource for conducting pharmacoepidemiological and health services research. Often, data are available for whole populations allowing population level analyses. Moreover, their routine collection ensures that the data reflect health care utilisation in the real-world setting compared to data collected in clinical trials. The Irish Health Service Executive-Primary Care Reimbursement Service (HSE-PCRS) community pharmacy claims database is described. The availability of demographic variables and drug-related information is discussed. The strengths and limitations associated using this database for conducting research are presented, in particular, internal and external validity. Examples of recently conducted research using the HSE-PCRS pharmacy claims database are used to illustrate the breadth of its use. The HSE-PCRS national pharmacy claims database is a large, high-quality, valid and accurate data source for measuring drug exposure in specific populations in Ireland. The main limitation is the lack of generalisability for those aged <70 years and the lack of information on indication or outcome.
Database Design to Ensure Anonymous Study of Medical Errors: A Report from the ASIPS collaborative

PubMed Central

Pace, Wilson D.; Staton, Elizabeth W.; Higgins, Gregory S.; Main, Deborah S.; West, David R.; Harris, Daniel M.

2003-01-01

Medical error reporting systems are important information sources for designing strategies to improve the safety of health care. Applied Strategies for Improving Patient Safety (ASIPS) is a multi-institutional, practice-based research project that collects and analyzes data on primary care medical errors and develops interventions to reduce error. The voluntary ASIPS Patient Safety Reporting System captures anonymous and confidential reports of medical errors. Confidential reports, which are quickly de-identified, provide better detail than do anonymous reports; however, concerns exist about the confidentiality of those reports should the database be subject to legal discovery or other security breaches. Standard database elements, for example, serial ID numbers, date/time stamps, and backups, could enable an outsider to link an ASIPS report to a specific medical error. The authors present the design and implementation of a database and administrative system that reduce this risk, facilitate research, and maintain near anonymity of the events, practices, and clinicians. PMID:12925548
[Analysis of demand for family medical care in Brazil using the International Classification of Primary Care].

PubMed

Landsberg, Gustavo de Araújo Porto; Savassi, Leonardo Cançado Monteiro; de Sousa, André Bonamigo; de Freitas, Janaína Miranda Rocha; Nascimento, Janaína Le Sann; Azagra, Rafael

2012-11-01

In various countries, motives for contact of patients with Primary Health Care (PHC) is classified by the International Classification of Primary Care (ICPC-2). This instrument enables the assessment of why people seek care, thereby assisting in planning strategies to attend the population's health needs. The scope of this study was to identify the main reasons for same-day appointments in PHC units of a medium-sized Brazilian city. The methodology used was to examine all records of a typical month of three family practice residents. Data were extracted from a secondary database of same-day appointments during the spring of 2010, classified with ICPC and then statistically analyzed. 1222 records were considered; 32 motives accounted for 50% of contacts. Most common motives were related to the General and Unspecific chapter of the ICPC. About 20% of visits occurred for administrative reasons. Female sex and greater age were determinants of greater motives for consultation. Knowing the motives for appointments by gender and age may help PHC teams in tackling health problems at the critical point of access to PHC.
A systematic review of interventions to provide genetics education for primary care.

PubMed

Paneque, Milena; Turchetti, Daniela; Jackson, Leigh; Lunt, Peter; Houwink, Elisa; Skirton, Heather

2016-07-22

At least 10 % of patients seen in primary care are said to have a condition in which genetics has an influence. However, patients at risk of genetic disease may not be recognised, while those who seek advice may not be referred or managed appropriately. Primary care practitioners lack knowledge of genetics and genetic testing relevant for daily practice and feel inadequate to deliver genetic services. The aim of this systematic review was to evaluate genetics educational interventions in the context of primary care. Following the process for systematic reviews developed by the Centre for Reviews and Dissemination, we conducted a search of five relevant electronic databases. Primary research papers were eligible for inclusion if they included data on outcomes of interventions regarding genetics education for primary care practitioners. The results from each paper were coded and grouped under themes. Eleven studies were included in the review. The five major themes identified inductively (post hoc) were: prior experience, changes in confidence, changes in knowledge, changes in practice, satisfaction and feedback. In five of the studies, knowledge of practitioners was improved following the educational programmes, but this tended to be in specific topic areas, while practitioner confidence improved in six studies. However, there was little apparent change to practice. There are insufficient studies of relevant quality to inform educational interventions in genetics for primary care practitioners. Educational initiatives should be assessed using changes in practice, as well as in confidence and knowledge, to determine if they are effective in causing significant changes in practice in genetic risk assessment and appropriate management of patients.

Readiness for the Patient-Centered Medical Home: structural capabilities of Massachusetts primary care practices.

PubMed

Friedberg, Mark W; Safran, Dana G; Coltin, Kathryn L; Dresser, Marguerite; Schneider, Eric C

2009-02-01

The Patient-Centered Medical Home (PCMH), a popular model for primary care reorganization, includes several structural capabilities intended to enhance quality of care. The extent to which different types of primary care practices have adopted these capabilities has not been previously studied. To measure the prevalence of recommended structural capabilities among primary care practices and to determine whether prevalence varies among practices of different size (number of physicians) and administrative affiliation with networks of practices. Cross-sectional analysis. One physician chosen at random from each of 412 primary care practices in Massachusetts was surveyed about practice capabilities during 2007. Practice size and network affiliation were obtained from an existing database. Presence of 13 structural capabilities representing 4 domains relevant to quality: patient assistance and reminders, culture of quality, enhanced access, and electronic health records (EHRs). Three hundred eight (75%) physicians responded, representing practices with a median size of 4 physicians (range 2-74). Among these practices, 64% were affiliated with 1 of 9 networks. The prevalence of surveyed capabilities ranged from 24% to 88%. Larger practice size was associated with higher prevalence for 9 of the 13 capabilities spanning all 4 domains (P < 0.05). Network affiliation was associated with higher prevalence of 5 capabilities (P < 0.05) in 3 domains. Associations were not substantively altered by statistical adjustment for other practice characteristics. Larger and network-affiliated primary care practices are more likely than smaller, non-affiliated practices to have adopted several recommended capabilities. In order to achieve PCMH designation, smaller non-affiliated practices may require the greatest investments.
Effect of part-time practice on patient outcomes.

PubMed

Parkerton, Patricia H; Wagner, Edward H; Smith, Dean G; Straley, Hugh L

2003-09-01

Primary care physicians are spending fewer hours in direct patient care, yet it is not known whether reduced hours are associated with differences in patient outcomes. To determine whether patient outcomes vary with physicians' clinic hours. Cross-sectional retrospective design assessing primary care practices in 1998. All 25 outpatient-clinics of a single medical group in western Washington. One hundred ninety-four family practitioners and general internists, 80% of whom were part-time, who provided ambulatory primary care services to specified HMO patient panels. Physician appointment hours ranged from 10 to 35 per week (30% to 100% of full time). Twenty-three measures of individual primary care physician performance collected in an administrative database were aggregated into 4 outcome measures: cancer screening, diabetic management, patient satisfaction, and ambulatory costs. Multivariate regression on each of the 4 outcomes controlled for characteristics of physicians (administrative role, gender, seniority) and patient panels (size, case mix, age, gender). While the effects were small, part-time physicians had significantly higher rates for cancer screening (4% higher, P =.001), diabetic management (3% higher, P =.033), and for patient satisfaction (3% higher, P =.035). After controlling for potential confounders, there was no significant association with patient satisfaction (P =.212) or ambulatory costs (P =.323). Primary care physicians working fewer clinical hours were associated with higher quality performance than were physicians working longer hours, but with patient satisfaction and ambulatory costs similar to those of physicians working longer hours. The trend toward part-time clinical practice by primary care physicians may occur without harm to patient outcomes.
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
Epidemiology of iron deficiency anaemia in four European countries: a population-based study in primary care.

PubMed

Levi, Miriam; Rosselli, Matteo; Simonetti, Monica; Brignoli, Ovidio; Cancian, Maurizio; Masotti, Adriana; Pegoraro, Valeria; Cataldo, Nazarena; Heiman, Franca; Chelo, Manuela; Cricelli, Iacopo; Cricelli, Claudio; Lapi, Francesco

2016-12-01

Iron deficiency anaemia (IDA) is a global public health concern, being responsible for about 800 000 deaths per year worldwide. To date, few studies have investigated the epidemiology of IDA in Europe. This study therefore aimed to assess the incidence rate and determinants of IDA in four European countries. Demographic and clinical information was obtained from four national primary care databases, respectively, for Italy, Belgium, Germany and Spain. IDA-related determinants were estimated using multivariable Cox regression. The annual incidence rates of IDA ranged between 7.2 and 13.96 per 1000 person-years. The estimates were higher in Spain and Germany. Females, younger and older patients were at greater risk of IDA, as well as those suffering from gastrointestinal diseases, pregnant women and those with history of menometrorrhagia, and aspirin and/or antacids users. A Charlson Index >0 was a significant determinant of IDA in all countries. The use of primary care databases allowed us to assess the incidence rate and determinants of IDA in four European countries. Given the crucial role of general practitioners in the diagnosis and management of this condition, our findings may contribute to increase the awareness of IDA among physicians as well as to reduce its occurrence among at-risk patients. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Behavioral medicine interventions for adult primary care settings: A review.

PubMed

Funderburk, Jennifer S; Shepardson, Robyn L; Wray, Jennifer; Acker, John; Beehler, Gregory P; Possemato, Kyle; Wray, Laura O; Maisto, Stephen A

2018-06-07

Health care organizations are embracing integrated primary care (IPC), in which mental health and behavioral health are addressed as part of routine care within primary care settings. Behavioral medicine concerns, which include health behavior change and coping with medical conditions, are common in primary care populations. Although there are evidence-based behavioral interventions that target a variety of behavioral medicine concerns, integrated behavioral health providers need interventions that are sufficiently brief (i.e., ≤6 appointments) to be compatible with IPC. We conducted a literature review of published studies examining behavioral interventions that target prevalent behavioral medicine concerns and can feasibly be employed by IPC providers in adult primary care settings. A total of 67 published articles representing 63 original studies met eligibility criteria. We extracted data on the behavioral interventions employed, results comparing the active intervention to a comparison group, general fit with IPC, and methodological quality. The vast majority of studies examined brief interventions targeting sleep difficulties and physical activity. The most commonly employed interventions were derived from cognitive-behavioral therapy and motivational interviewing. Outcomes were generally statistically significantly in favor of the active intervention relative to comparison, with highly variable methodological quality ratings (range = 0-5; M = 2.0). Results are discussed in relation to the need for further evidence for brief behavioral interventions targeting other behavioral medicine concerns beyond sleep and physical activity, as well as for more specificity regarding the compatibility of such interventions with IPC practice. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review.

PubMed

O'Reilly, Pauline; Lee, Siew Hwa; O'Sullivan, Madeleine; Cullen, Walter; Kennedy, Catriona; MacFarlane, Anne

2017-01-01

Interdisciplinary team working is of paramount importance in the reform of primary care in order to provide cost-effective and comprehensive care. However, international research shows that it is not routine practice in many healthcare jurisdictions. It is imperative to understand levers and barriers to the implementation process. This review examines interdisciplinary team working in practice, in primary care, from the perspective of service providers and analyses 1 barriers and facilitators to implementation of interdisciplinary teams in primary care and 2 the main research gaps. An integrative review following the PRISMA guidelines was conducted. Following a search of 10 international databases, 8,827 titles were screened for relevance and 49 met the criteria. Quality of evidence was appraised using predetermined criteria. Data were analysed following the principles of framework analysis using Normalisation Process Theory (NPT), which has four constructs: sense making, enrolment, enactment, and appraisal. The literature is dominated by a focus on interdisciplinary working between physicians and nurses. There is a dearth of evidence about all NPT constructs apart from enactment. Physicians play a key role in encouraging the enrolment of others in primary care team working and in enabling effective divisions of labour in the team. The experience of interdisciplinary working emerged as a lever for its implementation, particularly where communication and respect were strong between professionals. A key lever for interdisciplinary team working in primary care is to get professionals working together and to learn from each other in practice. However, the evidence base is limited as it does not reflect the experiences of all primary care professionals and it is primarily about the enactment of team working. We need to know much more about the experiences of the full network of primary care professionals regarding all aspects of implementation work. International Prospective Register of Systematic Reviews PROSPERO 2015: CRD42015019362.
Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review

PubMed Central

O’Reilly, Pauline; Lee, Siew Hwa; O’Sullivan, Madeleine; Cullen, Walter; Kennedy, Catriona; MacFarlane, Anne

2017-01-01

Background Interdisciplinary team working is of paramount importance in the reform of primary care in order to provide cost-effective and comprehensive care. However, international research shows that it is not routine practice in many healthcare jurisdictions. It is imperative to understand levers and barriers to the implementation process. This review examines interdisciplinary team working in practice, in primary care, from the perspective of service providers and analyses 1 barriers and facilitators to implementation of interdisciplinary teams in primary care and 2 the main research gaps. Methods and findings An integrative review following the PRISMA guidelines was conducted. Following a search of 10 international databases, 8,827 titles were screened for relevance and 49 met the criteria. Quality of evidence was appraised using predetermined criteria. Data were analysed following the principles of framework analysis using Normalisation Process Theory (NPT), which has four constructs: sense making, enrolment, enactment, and appraisal. The literature is dominated by a focus on interdisciplinary working between physicians and nurses. There is a dearth of evidence about all NPT constructs apart from enactment. Physicians play a key role in encouraging the enrolment of others in primary care team working and in enabling effective divisions of labour in the team. The experience of interdisciplinary working emerged as a lever for its implementation, particularly where communication and respect were strong between professionals. Conclusion A key lever for interdisciplinary team working in primary care is to get professionals working together and to learn from each other in practice. However, the evidence base is limited as it does not reflect the experiences of all primary care professionals and it is primarily about the enactment of team working. We need to know much more about the experiences of the full network of primary care professionals regarding all aspects of implementation work. Systematic review registration International Prospective Register of Systematic Reviews PROSPERO 2015: CRD42015019362. PMID:28545038
Interventions to improve care coordination between primary healthcare and oncology care providers: a systematic review.

PubMed

Tomasone, Jennifer R; Brouwers, Melissa C; Vukmirovic, Marija; Grunfeld, Eva; O'Brien, Mary Ann; Urquhart, Robin; Walker, Melanie; Webster, Fiona; Fitch, Margaret

2016-01-01

Coordination of patient care between primary care and oncology care providers is vital to care quality and outcomes across the cancer continuum, yet it is known to be challenging. We conducted a systematic review to evaluate current or new models of care and/or interventions aimed at improving coordination between primary care and oncology care providers for patients with adult breast and/or colorectal cancer. MEDLINE, EMBASE, CINAHL, Cochrane Library Database of Systematic Reviews, and the Centre for Reviews and Dissemination were searched for existing English language studies published between January 2000 and 15 May 2015. Systematic reviews, meta-analyses, randomised controlled trials (RCTs) and non-randomised studies were included if they evaluated a specific model/intervention that was designed to improve care coordination between primary care and oncology care providers, for any stage of the cancer continuum, for patients with adult breast and/or colorectal cancer. Two reviewers extracted data and assessed risk of bias. Twenty-two studies (5 systematic reviews, 6 RCTs and 11 non-randomised studies) were included and varied with respect to the targeted phase of the cancer continuum, type of model or intervention tested, and outcome measures. The majority of studies showed no statistically significant changes in any patient, provider or system outcomes. Owing to conceptual and methodological limitations in this field, the review is unable to provide specific conclusions about the most effective or preferred model/intervention to improve care coordination. Imprecise results that lack generalisability and definitiveness provide limited evidence to base the development of future interventions and policies. CRD42015025006.
Building a Patient-Reported Outcome Metric Database: One Hospital's Experience.

PubMed

Rana, Adam J

2016-06-01

A number of provisions exist within the Patient Protection and Affordable Care Act that focus on improving the delivery of health care in the United States, including quality of care. From a total joint arthroplasty perspective, the issue of quality increasingly refers to quantifying patient-reported outcome metrics (PROMs). This article describes one hospital's experience in building and maintaining an electronic PROM database for a practice of 6 board-certified orthopedic surgeons. The surgeons advocated to and worked with the hospital to contract with a joint registry database company and hire a research assistant. They implemented a standardized process for all surgical patients to fill out patient-reported outcome questionnaires at designated intervals. To date, the group has collected patient-reported outcome metric data for >4500 cases. The data are frequently used in different venues at the hospital including orthopedic quality metric and research meetings. In addition, the results were used to develop an annual outcome report. The annual report is given to patients and primary care providers, and portions of it are being used in discussions with insurance carriers. Building an electronic database to collect PROMs is a group undertaking and requires a physician champion. A considerable amount of work needs to be done up front to make its introduction a success. Once established, a PROM database can provide a significant amount of information and data that can be effectively used in multiple capacities. Copyright © 2016 Elsevier Inc. All rights reserved.
Nursing competency standards in primary health care: an integrative review.

PubMed

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

2016-05-01

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

PubMed

O'Brien, Doireann; Harvey, Kate; Howse, Jessica; Reardon, Tessa; Creswell, Cathy

2016-10-01

Mental health problems are common and typically have an early onset. Effective treatments for mental health problems in childhood and adolescence are available, yet only a minority of children who are affected access them. This is of serious concern, considering the far-reaching and long-term negative consequences of such problems. Primary care is usually the first port of call for concerned parents so it is important to understand how primary care practitioners manage child and adolescent mental health problems and the barriers they face. To ascertain primary care practitioners' perceptions of the barriers that prevent effective management of child and adolescent mental health problems. A systematic review of qualitative and quantitative literature in a primary care setting. A database search of peer-reviewed articles using PsycINFO, MEDLINE(®), Embase, and Web of Science, from inception (earliest 1806) until October 2014, was conducted. Additional studies were identified through hand searches and forward-citation searches. Studies needed to have at least one search term in four categories: primary care, childhood/adolescence, mental health, and barriers. A total of 4151 articles were identified, of which 43 were included (30 quantitative studies and 13 qualitative studies). The majority of the barriers related to identification, management, and/or referral. Considerable barriers included a lack of providers and resources, extensive waiting lists, and financial restrictions. The identification of a broad range of significant barriers highlights the need to strengthen the ability to deal with these common difficulties in primary care. There is a particular need for tools and training to aid accurate identification and management, and for more efficient access to specialist services. © British Journal of General Practice 2016.
Barriers to managing child and adolescent mental health problems: a systematic review of primary care practitioners’ perceptions

PubMed Central

O’Brien, Doireann; Harvey, Kate; Howse, Jessica; Reardon, Tessa; Creswell, Cathy

2016-01-01

Background Mental health problems are common and typically have an early onset. Effective treatments for mental health problems in childhood and adolescence are available, yet only a minority of children who are affected access them. This is of serious concern, considering the far-reaching and long-term negative consequences of such problems. Primary care is usually the first port of call for concerned parents so it is important to understand how primary care practitioners manage child and adolescent mental health problems and the barriers they face. Aim To ascertain primary care practitioners’ perceptions of the barriers that prevent effective management of child and adolescent mental health problems. Design and setting A systematic review of qualitative and quantitative literature in a primary care setting. Method A database search of peer-reviewed articles using PsycINFO, MEDLINE®, Embase, and Web of Science, from inception (earliest 1806) until October 2014, was conducted. Additional studies were identified through hand searches and forward-citation searches. Studies needed to have at least one search term in four categories: primary care, childhood/adolescence, mental health, and barriers. Results A total of 4151 articles were identified, of which 43 were included (30 quantitative studies and 13 qualitative studies). The majority of the barriers related to identification, management, and/or referral. Considerable barriers included a lack of providers and resources, extensive waiting lists, and financial restrictions. Conclusion The identification of a broad range of significant barriers highlights the need to strengthen the ability to deal with these common difficulties in primary care. There is a particular need for tools and training to aid accurate identification and management, and for more efficient access to specialist services. PMID:27621291
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.
Cost of best-practice primary care management of chronic disease in a remote Aboriginal community.

PubMed

Gador-Whyte, Andrew P; Wakerman, John; Campbell, David; Lenthall, Sue; Struber, Janet; Hope, Alex; Watson, Colin

2014-06-16

To estimate the cost of completing all chronic care tasks recommended by the Central Australian Rural Practitioners Association Standard Treatment Manual (CARPA STM) for patients with type 2 diabetes and chronic kidney disease (CKD). The study was conducted at a health service in a remote Central Australian Aboriginal community between July 2010 and May 2011. The chronic care tasks required were ascertained from the CARPA STM. The clinic database was reviewed for data on disease prevalence and adherence to CARPA STM guidelines. Recommended tasks were observed in a time-and-motion study of clinicians' work. Clinicians were interviewed about systematic management and its barriers. Expenditure records were analysed for salary and administrative costs. Diabetes and CKD prevalence; time spent on chronic disease care tasks; completion of tasks recommended by the CARPA STM; barriers to systematic care identified by clinicians; and estimated costs of optimal primary care management of all residents with diabetes or CKD. Projected annual costs of best-practice care for diabetes and CKD for this community of 542 people were $900 792, of which $645 313 would be met directly by the local primary care service. Estimated actual expenditure for these conditions in 2009-10 was $446 585, giving a projected funding gap of $198 728 per annum, or $1733 per patient. High staff turnover, acute care workload and low health literacy also hindered optimal chronic disease care. Barriers to optimal care included inadequate funding and workforce issues. Reduction of avoidable hospital admissions and overall costs necessitates adequate funding of primary care of chronic disease in remote communities.
“Burden of osteoporotic fractures in primary health care in Catalonia (Spain): a population-based study”

PubMed Central

2012-01-01

Background Knowledge on the epidemiology of non-hip fractures in Spain is limited and somewhat outdated. Using computerized primary care records from the SIDIAP database, we derived age and sex-specific fracture incidence rates for the region of Catalonia during the year 2009. Methods The SIDIAP database contains quality-checked clinical information from computerized medical records of a representative sample of >5,800,000 patients (80% of the population of Catalonia). We conducted a retrospective cohort study including all patients aged ≥50 years, and followed them from January 1 to December 31, 2009. Major osteoporotic fractures registered in SIDIAP were ascertained using ICD-10 codes and validated by comparing data to hospital admission and patient-reported fractures records. Incidence rates and 95% confidence intervals were calculated. Results In total, 2,011,430 subjects were studied (54.6% women). Overall fracture rates were 10.91/1,000 person-years (py) [95%CI 10.89–10.92]: 15.18/1,000 py [15.15–15.21] in women and 5.78/1,000 py [5.76–5.79] in men. The most common fracture among women was wrist/forearm (3.86/1,000 py [3.74–3.98]), while among men it was clinical spine (1.25/1,000 py [1.18–1.33]). All fracture rates increased with age, but varying patterns were observed: while most of the fractures (hip, proximal humerus, clinical spine and pelvis) increased continuously with age, wrist and multiple rib fractures peaked at age 75–80 and then reached a plateau. Conclusions Our study provides local estimates of age, sex and site-specific fracture burden in primary health care, which will be helpful for health-care planning and delivery. A proportion of fractures are not reported in primary care records, leading to underestimation of fracture incidence rates in these data. PMID:22639802
Reusability of coded data in the primary care electronic medical record: A dynamic cohort study concerning cancer diagnoses.

PubMed

Sollie, Annet; Sijmons, Rolf H; Helsper, Charles; Numans, Mattijs E

2017-03-01

To assess quality and reusability of coded cancer diagnoses in routine primary care data. To identify factors that influence data quality and areas for improvement. A dynamic cohort study in a Dutch network database containing 250,000 anonymized electronic medical records (EMRs) from 52 general practices was performed. Coded data from 2000 to 2011 for the three most common cancer types (breast, colon and prostate cancer) was compared to the Netherlands Cancer Registry. Data quality is expressed in Standard Incidence Ratios (SIRs): the ratio between the number of coded cases observed in the primary care network database and the expected number of cases based on the Netherlands Cancer Registry. Ratios were multiplied by 100% for readability. The overall SIR was 91.5% (95%CI 88.5-94.5) and showed improvement over the years. SIRs differ between cancer types: from 71.5% for colon cancer in males to 103.9% for breast cancer. There are differences in data quality (SIRs 76.2% - 99.7%) depending on the EMR system used, with SIRs up to 232.9% for breast cancer. Frequently observed errors in routine healthcare data can be classified as: lack of integrity checks, inaccurate use and/or lack of codes, and lack of EMR system functionality. Re-users of coded routine primary care Electronic Medical Record data should be aware that 30% of cancer cases can be missed. Up to 130% of cancer cases found in the EMR data can be false-positive. The type of EMR system and the type of cancer influence the quality of coded diagnosis registry. While data quality can be improved (e.g. through improving system design and by training EMR system users), re-use should only be taken care of by appropriately trained experts. Copyright © 2016. Published by Elsevier B.V.
Pressure Injuries in Inpatient Care Facilities in the Czech Republic: Analysis of a National Electronic Database.

PubMed

Pokorná, Andrea; Benešová, Klára; Jarkovský, Jirˇí; Mužík, Jan; Beeckman, Dimitri

The purpose of this study was to analyze pressure injury (PI) occurrence upon admission and at any time during the hospital course inpatients care facilities in the Czech Republic. Secondary aims were to evaluate demographic and clinical data of patients with PI and the impact of a PI on length of stay (LOS) in the hospital. Retrospective, cross-sectional analysis. The sample comprised data of hospitalized patients entered into the National Register of Hospitalized Patients (NRHOSP) database of the Czech Republic between 2007 and 2014 with a diagnosis L89 (pressure ulcer of unspecified site based on the International Classification of Diseases, Tenth Revision, ICD-10). Electronic records of 17,762,854 hospitalizations were reviewed. Data from the NRHOSP from all acute and non-acute care hospitals in the Czech Republic were analyzed. Specifically, we analyzed patients admitted to acute and non-acute care facilities with a primary or secondary diagnosis of PI. The NRHOSP database included 17,762,854 cases, of which 46,224 cases (33,342 cases in acute care hospitals; 12,882 in non-acute care hospitals) had the L89 diagnosis (0.3%). The mean age of patients admitted with a PI was 73.8 ± 15.3 years (mean ± SD), and their average LOS was 33.2 ± 76.9 days. The mean LOS of patients hospitalized with L89 code as a primary diagnosis (n = 6877) was significantly longer compared to those patients for whom L89 code was a secondary diagnosis (25.8 vs 20.2 days, P < .001) in acute care facilities. In contrast, we found no difference in the mean LOS for patients hospitalized in non-acute care facility (58.7 days vs 65.1 days; P = .146) with ICD code L89. Pressure injuries were associated with significant LOS in both acute and non-acute care settings in the Czech Republic. Despite the valuable insights we obtained from the analysis of NRHOSP data, we advocate creation of a more valid and reliable electronic reporting system that enables policy makers to evaluate the quality and safety concerning PI and its impact on patients and the healthcare system.
An Evaluation of Algorithms for Identifying Metastatic Breast, Lung, or Colorectal Cancer in Administrative Claims Data.

PubMed

Whyte, Joanna L; Engel-Nitz, Nicole M; Teitelbaum, April; Gomez Rey, Gabriel; Kallich, Joel D

2015-07-01

Administrative health care claims data are used for epidemiologic, health services, and outcomes cancer research and thus play a significant role in policy. Cancer stage, which is often a major driver of cost and clinical outcomes, is not typically included in claims data. Evaluate algorithms used in a dataset of cancer patients to identify patients with metastatic breast (BC), lung (LC), or colorectal (CRC) cancer using claims data. Clinical data on BC, LC, or CRC patients (between January 1, 2007 and March 31, 2010) were linked to a health care claims database. Inclusion required health plan enrollment ≥3 months before initial cancer diagnosis date. Algorithms were used in the claims database to identify patients' disease status, which was compared with physician-reported metastases. Generic and tumor-specific algorithms were evaluated using ICD-9 codes, varying diagnosis time frames, and including/excluding other tumors. Positive and negative predictive values, sensitivity, and specificity were assessed. The linked databases included 14,480 patients; of whom, 32%, 17%, and 14.2% had metastatic BC, LC, and CRC, respectively, at diagnosis and met inclusion criteria. Nontumor-specific algorithms had lower specificity than tumor-specific algorithms. Tumor-specific algorithms' sensitivity and specificity were 53% and 99% for BC, 55% and 85% for LC, and 59% and 98% for CRC, respectively. Algorithms to distinguish metastatic BC, LC, and CRC from locally advanced disease should use tumor-specific primary cancer codes with 2 claims for the specific primary cancer >30-42 days apart to reduce misclassification. These performed best overall in specificity, positive predictive values, and overall accuracy to identify metastatic cancer in a health care claims database.
Methodological challenges when evaluating potential off-label prescribing of drugs using electronic health care databases: A case study of dabigatran etexilate in Europe.

PubMed

Cainzos-Achirica, Miguel; Varas-Lorenzo, Cristina; Pottegård, Anton; Asmar, Joelle; Plana, Estel; Rasmussen, Lotte; Bizouard, Geoffray; Forns, Joan; Hellfritzsch, Maja; Zint, Kristina; Perez-Gutthann, Susana; Pladevall-Vila, Manel

2018-03-23

To report and discuss estimated prevalence of potential off-label use and associated methodological challenges using a case study of dabigatran. Observational, cross-sectional study using 3 databases with different types of clinical information available: Cegedim Strategic Data Longitudinal Patient Database (CSD-LPD), France (cardiologist panel, n = 1706; general practitioner panel, n = 2813; primary care data); National Health Databases, Denmark (n = 28 619; hospital episodes and dispensed ambulatory medications); and Clinical Practice Research Datalink (CPRD), UK (linkable to Hospital Episode Statistics [HES], n = 2150; not linkable, n = 1285; primary care data plus hospital data for HES-linkable patients). August 2011 to August 2015. Two definitions were used to estimate potential off-label use: a broad definition of on-label prescribing using codes for disease indication (eg, atrial fibrillation [AF]), and a restrictive definition excluding patients with conditions for which dabigatran is not indicated (eg, valvular AF). Prevalence estimates under the broad definition ranged from 5.7% (CPRD-HES) to 34.0% (CSD-LPD) and, under the restrictive definition, from 17.4% (CPRD-HES) to 44.1% (CSD-LPD). For the majority of potential off-label users, no diagnosis potentially related to anticoagulant use was identified. Key methodological challenges were the limited availability of detailed clinical information, likely leading to overestimation of off-label use, and differences in the information available, which may explain the disparate prevalence estimates across data sources. Estimates of potential off-label use should be interpreted cautiously due to limitations in available information. In this context, CPRD HES-linkable estimates are likely to be the most accurate. Copyright © 2018 John Wiley & Sons, Ltd.
[Morbidity and drug consumption. Comparison of results between the National Health Survey and electronic medical records].

PubMed

Aguilar-Palacio, Isabel; Carrera-Lasfuentes, Patricia; Poblador-Plou, Beatriz; Prados-Torres, Alexandra; Rabanaque-Hernández, M José

2014-01-01

To compare the prevalence of disease and drug consumption obtained by using the National Health Survey (NHS) with the information provided by the electronic medical records (EMR) in primary health care and the Pharmaceutical Consumption Registry in Aragon (Farmasalud) in the adult population in the province of Zaragoza. A cross-sectional study was performed to compare the prevalence of diseases in the NHS-2006 and in the EMR. The prevalence of drug consumption was obtained from the NHS-2006 and Farmasalud. Estimations using each database were compared with their 95% confidence intervals (95% CI) and the results were stratified by gender and age groups. The comparability of the databases was tested. According to the NHS, a total of 81.8% of the adults in the province of Zaragoza visited a physician in 2006. According to the EMR, 61.4% of adults visited a primary care physician. The most prevalent disease in both databases was hypertension (NHS: 21.5%, 95% CI: 19.4-23.9; EMR: 21.6%, 95% CI: 21.3-21.8). The greatest differences between the NHS and EMR was observed in the prevalence of depression, anxiety, and other mental illnesses (NHS: 10.9%; EMR: 26.6%). The most widely consumed drugs were analgesics The prevalence of drug consumption differed in the two databases, with the greatest differences being found in pain medication (NHS: 23.3%; Farmasalud: 63.8%) and antibiotics (NHS: 3.4%; Farmasalud: 41.7%). These differences persisted after we stratified by gender and were especially important in the group aged more than 75 years. The prevalence of morbidity and drug consumption differed depending on the database employed. The use of different databases is recommended to estimate real prevalences. Copyright © 2013 SESPAS. Published by Elsevier Espana. All rights reserved.

Primary Payer at DX: Issues with Collection and Assessment of Data Quality.

PubMed

Sherman, Recinda L; Williamson, Laura; Andrews, Patricia; Kahn, Amy

2016-01-01

An individual's access to health insurance influences the amount and type of health services a patient receives for prevention and treatment, and, ultimately, influences survival. The North American Association of Central Cancer Registries (NAACCR) Item #630, Primary Payer at DX, is a required field intended to document health insurance status for the purpose of supporting patterns-of-care studies and other research. However, challenges related to the uniformity of collection and availability of data needed to populate this field diminish the value of the Primary Payer at DX data. A NAACCR taskforce worked on issues surrounding the collection of Primary Payer at DX; including proposing a crosswalk between Primary Payer at DX and the new Public Health Payment Typology standard, often available in hospital discharge databases. However, there are issues with compatibility between coding systems, intent of data collection, timelines for coding insurance, and changes in insurance coverage (partly due to the Affordable Care Act) that continue to complicate the collection and use of Primary Payer at DX data.
Need, access, and the reach of integrated care: A typology of patients.

PubMed

Bridges, Ana J; Villalobos, Bianca T; Anastasia, Elizabeth A; Dueweke, Aubrey R; Gregus, Samantha J; Cavell, Timothy A

2017-06-01

This paper is a report on a study exploring a potential typology of primary care patients referred for integrated behavioral health care (IBHC) services. We considered whether primary care patients could be grouped into meaningful clusters based on perceived need for behavioral health services, barriers to accessing care, and past-year service utilization. We also described the development of a working partnership between our university-based research team and a federally qualified health center (FQHC). A total of 105 adult primary care patients referred for same-day behavioral health appointments completed a brief self-report questionnaire assessing past-year behavioral health concerns, service utilization, and perceived barriers to utilization. Hierarchical and k-means cluster analyses revealed 3 groups: (a) Well-Served patients, characterized by high perceived need for services, high service use, and low barriers to service use (40%); (b) Underserved patients, characterized by high perceived need, low service utilization, and high barriers to service use (20%); and (c) Subclinical patients, characterized by low perceived need, low service use, and low barriers to service use (20%). Clusters were reliably differentiated by age, primary language, insurance status, and global functioning. We found primary care patients could be grouped into 3 categories and that 60% (Underserved and Subclinical) represented groups less commonly seen in traditional mental health (MH) settings. IBHC may be a promising approach for extending the reach of MH care, and partnerships between FQHCs and university-based research teams may be a promising approach for conducting research on the IBHC service-delivery model. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
Integration and continuity of Care in health care network models for frail older adults

PubMed Central

Veras, Renato Peixoto; Caldas, Célia Pereira; da Motta, Luciana Branco; de Lima, Kenio Costa; Siqueira, Ricardo Carreño; Rodrigues, Renata Teixeira da Silva Vendas; Santos, Luciana Maria Alves Martins; Guerra, Ana Carolina Lima Cavaletti

2014-01-01

A detailed review was conducted of the literature on models evaluating the effectiveness of integrated and coordinated care networks for the older population. The search made use of the following bibliographic databases: Pubmed, The Cochrane Library, LILACS, Web of Science, Scopus and SciELO. Twelve articles on five different models were included for discussion. Analysis of the literature showed that the services provided were based on primary care, including services within the home. Service users relied on the integration of primary and hospital care, day centers and in-home and social services. Care plans and case management were key elements in care continuity. This approach was shown to be effective in the studies, reducing the need for hospital care, which resulted in savings for the system. There was reduced prevalence of functional loss and improved satisfaction and quality of life on the part of service users and their families. The analysis reinforced the need for change in the approach to health care for older adults and the integration and coordination of services is an efficient way of initiating this change. PMID:24897058
Increased registration of hypertension and cancer diagnoses after the introduction of a new reimbursement system.

PubMed

Hjerpe, Per; Boström, Kristina Bengtsson; Lindblad, Ulf; Merlo, Juan

2012-12-01

To investigate the impact on ICD coding behaviour of a new case-mix reimbursement system based on coded patient diagnoses. The main hypothesis was that after the introduction of the new system the coding of chronic diseases like hypertension and cancer would increase and the variance in propensity for coding would decrease on both physician and health care centre (HCC) levels. Cross-sectional multilevel logistic regression analyses were performed in periods covering the time before and after the introduction of the new reimbursement system. Skaraborg primary care, Sweden. All patients (n = 76 546 to 79 826) 50 years of age and older visiting 468 to 627 physicians at the 22 public HCCs in five consecutive time periods of one year each. Registered codes for hypertension and cancer diseases in Skaraborg primary care database (SPCD). After the introduction of the new reimbursement system the adjusted prevalence of hypertension and cancer in SPCD increased from 17.4% to 32.2% and from 0.79% to 2.32%, respectively, probably partly due to an increased diagnosis coding of indirect patient contacts. The total variance in the propensity for coding declined simultaneously at the physician level for both diagnosis groups. Changes in the healthcare reimbursement system may directly influence the contents of a research database that retrieves data from clinical practice. This should be taken into account when using such a database for research purposes, and the data should be validated for each diagnosis.
Clinical Databases for Chest Physicians.

PubMed

Courtwright, Andrew M; Gabriel, Peter E

2018-04-01

A clinical database is a repository of patient medical and sociodemographic information focused on one or more specific health condition or exposure. Although clinical databases may be used for research purposes, their primary goal is to collect and track patient data for quality improvement, quality assurance, and/or actual clinical management. This article aims to provide an introduction and practical advice on the development of small-scale clinical databases for chest physicians and practice groups. Through example projects, we discuss the pros and cons of available technical platforms, including Microsoft Excel and Access, relational database management systems such as Oracle and PostgreSQL, and Research Electronic Data Capture. We consider approaches to deciding the base unit of data collection, creating consensus around variable definitions, and structuring routine clinical care to complement database aims. We conclude with an overview of regulatory and security considerations for clinical databases. Copyright © 2018 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
[Coding in general practice-Will the ICD-11 be a step forward?

PubMed

Kühlein, Thomas; Virtanen, Martti; Claus, Christoph; Popert, Uwe; van Boven, Kees

2018-07-01

Primary care physicians in Germany don't benefit from coding diagnoses-they are coding for the needs of others. For coding, they mostly are using either the thesaurus of the German Institute of Medical Documentation and Information (DIMDI) or self-made cheat-sheets. Coding quality is low but seems to be sufficient for the main use case of the resulting data, which is the morbidity adjusted risk compensation scheme that distributes financial resources between the many German health insurance companies.Neither the International Classification of Diseases and Health Related Problems (ICD-10) nor the German thesaurus as an interface terminology are adequate for coding in primary care. The ICD-11 itself will not recognizably be a step forward from the perspective of primary care. At least the browser database format will be advantageous. An implementation into the 182 different electronic health records (EHR) on the German market would probably standardize the coding process and make code finding easier. This method of coding would still be more cumbersome than the current coding with self-made cheat-sheets.The first steps towards a useful official cheat-sheet for primary care have been taken, awaiting implementation and evaluation. The International Classification of Primary Care (ICPC-2) already provides an adequate classification standard for primary care that can also be used in combination with ICD-10. A new version of ICPC (ICPC-3) is under development. As the ICPC-2 has already been integrated into the foundation layer of ICD-11 it might easily become the future standard for coding in primary care. Improving communication between the different EHR would make taking over codes from other healthcare providers possible. Another opportunity to improve the coding quality might be creating use cases for the resulting data for the primary care physicians themselves.
Reducing hospital readmission through team-based primary care: A 7-week pilot study integrating behavioral health and pharmacy.

PubMed

DeCaporale-Ryan, Lauren N; Ahmed-Sarwar, Nabila; Upham, Robbyn; Mahler, Karen; Lashway, Katie

2017-06-01

A team-based service delivery model was applied to provide patients with biopsychosocial care following hospital discharge to reduce hospital readmission. Most previous interventions focused on transitions of care occurred in the inpatient setting with attention to predischarge strategies. These interventions have not considered psychosocial stressors, and few have explored management in primary care settings. A 7-week team-based service delivery model was implemented in a family medicine practice emphasizing a biopsychosocial approach. A physician, psychologist, pharmacist, care managers, and interdisciplinary trainees worked with 17 patients following hospital discharge. This comprehensive evaluation assessed patients' mood, cognitive abilities, and self-management of health behaviors. Modifications were made to improve ease of access to outpatient care and to improve patient understanding of the therapeutic plan. This pilot study was conducted to determine the utility of the model. Of 17 patients, 15 individuals avoided readmission at 30- and 90-day intervals. Other substantial benefits were noted, including reduced polypharmacy, engagement in specialty care, and reduction of environmental stressors to improve access to care. The clinic in which this was implemented is currently making efforts to maintain this model of care based on observed success. Although this work only represents a small sample, results are encouraging. This model can be replicated in other primary care settings with specialty clinicians on site. Specifically, approaches that promote a team-based delivery in a primary care setting may support improved patient outcomes and reduced overall systems' costs. Recommendations for research in a clinical setting are also offered. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
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.
Primary care workforce shortages and career recommendations from practicing clinicians.

PubMed

DesRoches, Catherine M; Buerhaus, Peter; Dittus, Robert S; Donelan, Karen

2015-05-01

The success of efforts to bolster the primary care workforce rests in part on how these clinicians view their professions and their willingness to recommend their careers to others. The authors sought to examine career and job satisfaction, perceptions of workforce shortages, and willingness to make career recommendations among primary care physicians (PCPs) and primary care nurse practitioners (PCNPs). In 2012, the authors mailed a national survey concerning the issues above to 1,914 randomly chosen clinicians found on national databases: 957 PCPs and 957 PCNPs. A total of 972 eligible clinicians (505 PCPs, 467 PCNPs) returned the survey. Using standard opinion research procedures, the authors estimated there were approximately 1,589 eligible clinicians in their sample (response rate, 61.2%). PCNPs and PCPs were more likely to recommend a career as a PCNP than as a PCP, despite the perception among all clinicians of a serious shortage of PCPs nationally and in their own communities. This finding held among PCNPs who reported low workplace autonomy and among PCPs reporting that they were satisfied with their own careers. Efforts to solve the primary care workforce shortage that ignore the significant dissatisfaction of PCPs with their own careers are unlikely to be successful. Simply adding training slots and increasing reimbursement rates will do little to solve the problem if PCPs continue to view their own careers as ones they cannot recommend to others.
Recruitment and retention of rural physicians: outcomes from the rural physician associate program of Minnesota.

PubMed

Halaas, Gwen Wagstrom; Zink, Therese; Finstad, Deborah; Bolin, Keli; Center, Bruce

2008-01-01

Founded in 1971 with state funding to increase the number of primary care physicians in rural Minnesota, the Rural Physician Associate Program (RPAP) has graduated 1,175 students. Third-year medical students are assigned to primary care physicians in rural communities for 9 months where they experience the realities of rural practice with hands-on participation, mentoring, and one-to-one teaching. Students complete an online curriculum, participate in online discussion with fellow students, and meet face-to-face with RPAP faculty 6 times during the 9-month rotation. Projects designed to bring value to the community, including an evidence-based practice and community health assessment, are completed. To examine RPAP outcomes in recruiting and retaining rural primary care physicians. The RPAP database, including moves and current practice settings, was examined using descriptive statistics. On average, 82% of RPAP graduates have chosen primary care, and 68% family medicine. Of those currently in practice, 44% have practiced in a rural setting all of the time, 42% in a metropolitan setting and 14% have chosen both, with more than 50% of their time in rural practice. Rural origin has only a small association with choosing rural practice. RPAP data suggest that the 9-month longitudinal experience in a rural community increases the number of students choosing primary care practice, especially family medicine, in a rural setting.
The Readiness for Integrated Care Questionnaire (RICQ): An instrument to assess readiness to integrate behavioral health and primary care.

PubMed

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

2017-01-01

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

PubMed

Jaakkimainen, R Liisa; Shultz, Susan E; Tu, Karen

2013-09-01

Several barriers to the adoption of electronic medical records (EMRs) by family physicians have been discussed, including the costs of implementation, impact on work flow and loss of productivity. We examined billings and payments received before and after implementation of EMRs among primary care physicians in the province of Ontario. We also examined billings and payments before and after switching from a fee-for-service to a capitation payment model, because EMR implementation coincided with primary care reform in the province. We used information from the Electronic Medical Record Administrative Data Linked Database (EMRALD) to conduct a retrospective before-after study. The EMRALD database includes EMR data extracted from 183 community-based family physicians in Ontario. We included EMRALD physicians who were eligible to bill the Ontario Health Insurance Plan at least 18 months before and after the date they started using EMRs and had completed a full 18-month period before Mar. 31, 2011, when the study stopped. The main outcome measures were physicians' monthly billings and payments for office visits and total annual payments received from all government sources. Two index dates were examined: the date physicians started using EMRs and were in a stable payment model (n = 64) and the date physicians switched from a fee-for-service to a capitation payment model (n = 42). Monthly billings and payments for office visits did not decrease after the implementation of EMRs. The overall weighted mean annual payment from all government sources increased by 27.7% after the start of EMRs among EMRALD physicians; an increase was also observed among all other primary care physicians in Ontario, but it was not as great (14.4%). There was a decline in monthly billings and payments for office visits after physicians changed payment models, but an increase in their overall annual government payments. Implementation of EMRs by primary care physicians did not result in decreased billings or government payments for office visits. Further economic analyses are needed to measure the effects of EMR implementation on productivity and the costs of implementing an EMR system, including the costs of nonclinical work by physicians and their staff.
Organizational interventions improving access to community-based primary health care for vulnerable populations: a scoping review.

PubMed

Khanassov, Vladimir; Pluye, Pierre; Descoteaux, Sarah; Haggerty, Jeannie L; Russell, Grant; Gunn, Jane; Levesque, Jean-Frederic

2016-10-10

Access to community-based primary health care (hereafter, 'primary care') is a priority in many countries. Health care systems have emphasized policies that help the community 'get the right service in the right place at the right time'. However, little is known about organizational interventions in primary care that are aimed to improve access for populations in situations of vulnerability (e.g., socioeconomically disadvantaged) and how successful they are. The purpose of this scoping review was to map the existing evidence on organizational interventions that improve access to primary care services for vulnerable populations. Scoping review followed an iterative process. Eligibility criteria: organizational interventions in Organisation for Economic Cooperation and Development (OECD) countries; aiming to improve access to primary care for vulnerable populations; all study designs; published from 2000 in English or French; reporting at least one outcome (avoidable hospitalization, emergency department admission, or unmet health care needs). Main bibliographic databases (Medline, Embase, CINAHL) and team members' personal files. One researcher selected relevant abstracts and full text papers. Theory-driven synthesis: The researcher classified included studies using (i) the 'Patient Centered Access to Healthcare' conceptual framework (dimensions and outcomes of access to primary care), and (ii) the classification of interventions of the Cochrane Effective Practice and Organization of Care. Using pattern analysis, interventions were mapped in accordance with the presence/absence of 'dimension-outcome' patterns. Out of 8,694 records (title/abstract), 39 studies with varying designs were included. The analysis revealed the following pattern. Results of 10 studies on interventions classified as 'Formal integration of services' suggested that these interventions were associated with three dimensions of access (approachability, availability and affordability) and reduction of hospitalizations (four/four studies), emergency department admissions (six/six studies), and unmet healthcare needs (five/six studies). These 10 studies included seven non-randomized studies, one randomized controlled trial, one quantitative descriptive study, and one mixed methods study. Our results suggest the limited breadth of research in this area, and that it will be feasible to conduct a full systematic review of studies on the effectiveness of the formal integration of services to improve access to primary care services for vulnerable populations.
The effectiveness of motivational interviewing for health behaviour change in primary care settings: a systematic review.

PubMed

Morton, Katie; Beauchamp, Mark; Prothero, Anna; Joyce, Lauren; Saunders, Laura; Spencer-Bowdage, Sarah; Dancy, Bernadette; Pedlar, Charles

2015-01-01

Motivational interviewing (MI) is a patient-centred approach to behaviour change that was originally developed in the addiction field but has increasingly been applied to public health settings with a focus on health promotion. The purpose of this review was to examine the evidence base for MI interventions in primary care settings with non-clinical populations to achieve behaviour change for physical activity, dietary behaviours and/or alcohol intake. We also sought to explore the specific behaviour change techniques included in MI interventions within primary care. Electronic databases were searched for relevant articles and 33 papers met inclusion criteria and were included. Approximately 50% of the included studies (n = 18) demonstrated positive effects in relation to health behaviour change. The efficacy of MI approaches is unclear given the inconsistency of MI descriptions and intervention components. Furthermore, research designs that do not isolate the effects of MI make it difficult to determine the effectiveness of such approaches. We offer a number of recommendations for researchers and practitioners seeking to include MI within behaviour change interventions to help improve the quality of the research and the effectiveness of MI-based interventions within primary care settings.
Jaundice in primary care: a cohort study of adults aged >45 years using electronic medical records.

PubMed

Taylor, Anna; Stapley, Sally; Hamilton, William

2012-08-01

Jaundice is a rare but important symptom of malignant and benign conditions. When patients present in primary care, understanding the relative likelihood of different disease processes can help GPs to investigate and refer patients appropriately. To identify and quantify the various causes of jaundice in adults presenting in primary care. Historical cohort study using electronic primary care records. UK General Practice Research Database. Participants (186 814 men and women) aged >45 years with clinical events recorded in primary care records between 1 January 2005 and 31 December 2007. Data were searched for episodes of jaundice and explanatory diagnoses identified within the subsequent 12 months. If no diagnosis was found, the patient's preceding medical record was searched for relevant chronic diseases. From the full cohort, 277 patients had at least one record of jaundice between 1 January 2005 and 31 December 2006. Ninety-two (33%) were found to have bile duct stones; 74 (27%) had an explanatory cancer [pancreatic cancer 34 (12%), cholangiocarcinoma 13 (5%) and other diagnosed primary malignancy 27 (10%)]. Liver disease attributed to excess alcohol explained 26 (9%) and other diagnoses were identified in 24 (9%). Sixty-one (22%) had no diagnosis related to jaundice recorded. Although the most common cause of jaundice is bile duct stones, cancers are present in over a quarter of patients with jaundice in this study, demonstrating the importance of urgent investigation into the underlying cause.
[Risk factors and burnout levels in Primary Care nurses: A systematic review].

PubMed

Gómez-Urquiza, Jose L; Monsalve-Reyes, Carolina S; San Luis-Costas, Concepción; Fernández-Castillo, Rafael; Aguayo-Estremera, Raimundo; Cañadas-de la Fuente, Guillermo A

2017-02-01

To determine the risk factors and levels of burnout in Primary Care nurses. A systematic review was performed. CINAHL, CUIDEN, LILACS, PubMed, ProQuest, ScienceDirect and Scopus databases were consulted. Search equations were 'burnout AND community health nursing' and 'burnout AND primary care nursing'. The search was performed in October 2015. The final sample was n=12 studies. Quantitative primary studies that used Maslach Burnout Inventory for burnout assessment in Primary Care nurses were included without restriction by publication date. The main variables were the mean and standard deviation of the three burnout dimensions, high, medium and low prevalence rates of each dimension, and socio-demographic, occupational and psychological variables that potentially influence burnout level. Studies show high prevalence rates, generally between 23% and 31%, of emotional exhaustion. The prevalence rates of high depersonalisation and low personal accomplishment show heterogeneity, varying between 8%-32% and 4%-92% of the sample, respectively. Studies show that older nurses with more seniority, anxiety and depression, among other variables, have higher burnout levels, while nurses with higher salary, high job satisfaction, organisational support, and good self-concept have less burnout. High emotional exhaustion is the main affected dimension of burnout in Primary Care nursing. There is heterogeneity in depersonalisation and personal accomplishment. Burnout must be prevented in these professionals, by increasing protective factors and monitoring its appearance in those with risk factors. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.
Pharmacist-led, primary care-based disease management improves hemoglobin A1c in high-risk patients with diabetes.

PubMed

Rothman, Russell; Malone, Robb; Bryant, Betsy; Horlen, Cheryl; Pignone, Michael

2003-01-01

We developed and evaluated a comprehensive pharmacist-led, primary care-based diabetes disease management program for patients with Type 2 diabetes and poor glucose control at our academic general internal medicine practice. The primary goal of this program was to improve glucose control, as measured by hemoglobin A1c (HbA1c). Clinic-based pharmacists offered support to patients with diabetes through direct teaching about diabetes, frequent phone follow-up, medication algorithms, and use of a database that tracked patient outcomes and actively identified opportunities to improve care. From September 1999, to May 2000, 159 subjects were enrolled, and complete follow-up data were available for 138 (87%) patients. Baseline HbA1c averaged 10.8%, and after an average of 6 months of intervention, the mean reduction in HbA1c was 1.9 percentage points (95% confidence interval, 1.5-2.3). In predictive regression modeling, baseline HbA1c and new onset diabetes were associated with significant improvements in HbA1c. Age, race, gender, educational level, and provider status were not significant predictors of improvement. In conclusion, a pharmacist-based diabetes care program integrated into primary care practice significantly reduced HbA1c among patients with diabetes and poor glucose control.
DIAGNOSIS AND TREATMENT OF ADHD DURING ADOLESCENCE IN THE PRIMARY CARE SETTING: REVIEW AND FUTURE DIRECTIONS

PubMed Central

Brahmbhatt, Khyati; Hilty, Donald M.; Hah, Mina; Han, Jaesu; Angkustsiri, Kathy; Schweitzer, Julie

2017-01-01

Introduction Attention deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder with a worldwide prevalence of about 5% in school age children. Objective The goal of this review is to assist primary care providers (PCPs) in diagnosing and treating ADHD in adolescents. Methods PubMed, PsychInfo and Science Citation Index databases were searched from March 1990–2015 with the key words: attention deficit hyperactivity disorder, primary care/pediatrics and children/adolescents, abstracts addressing diagnosis and/or treatment with 105 citations identified including supplementary treatment guidelines/books. Results Adolescent ADHD presents with significant disturbances in attention, academic performance and family relationships with unique issues associated with this developmental period. Diagnostic challenges include the variable symptom presentation during adolescence, complex differential diagnosis and limited training and time for PCPs to conduct thorough evaluations. The evidence-base for treatments in adolescence in comparison to those in children or adults with ADHD is relatively weak. Providers should be cognizant of prevention, early identification and treatment of conditions associated with ADHD that emerge during adolescence as substance use disorders. Conclusions Adolescent ADHD management for the PCP is complex, requires further research, and perhaps new primary care-psychiatric models, to assist in determining the optimal care for patients at this critical period. PMID:27209327
Designing Reliable Cohorts of Cardiac Patients across MIMIC and eICU

PubMed Central

Chronaki, Catherine; Shahin, Abdullah; Mark, Roger

2016-01-01

The design of the patient cohort is an essential and fundamental part of any clinical patient study. Knowledge of the Electronic Health Records, underlying Database Management System, and the relevant clinical workflows are central to an effective cohort design. However, with technical, semantic, and organizational interoperability limitations, the database queries associated with a patient cohort may need to be reconfigured in every participating site. i2b2 and SHRINE advance the notion of patient cohorts as first class objects to be shared, aggregated, and recruited for research purposes across clinical sites. This paper reports on initial efforts to assess the integration of Medical Information Mart for Intensive Care (MIMIC) and Philips eICU, two large-scale anonymized intensive care unit (ICU) databases, using standard terminologies, i.e. LOINC, ICD9-CM and SNOMED-CT. Focus of this work is lab and microbiology observations and key demographics for patients with a primary cardiovascular ICD9-CM diagnosis. Results and discussion reflecting on reference core terminology standards, offer insights on efforts to combine detailed intensive care data from multiple ICUs worldwide. PMID:27774488
Breast cancer screening utilization among women from Muslim majority countries in Ontario, Canada.

PubMed

Vahabi, Mandana; Lofters, Aisha; Kim, Eliane; Wong, Josephine Pui-Hing; Ellison, Lisa; Graves, Erin; Glazier, Richard H

2017-12-01

Breast cancer screening disparities continue to prevail with immigrant women being at the forefront of the under screened population. There is a paucity of knowledge about the role of religious affiliation or cultural orientation on immigrant women's cancer screening uptake. This study examined differences in uptake of breast cancer screening among women from Muslim and non- Muslim majority countries in Ontario, Canada. A cohort of 1,851,834 screening-eligible women living in Ontario during April 1, 2013 to March 31, 2015 was created using linked health and social administrative databases. The study found that being born in a Muslim majority country was associated with lower breast cancer screening uptake after adjusting for region of origin, neighbourhood income, and primary care-related factors. However, screening uptake in Muslim majority countries varied by world region with the greatest differences found in Sub-Saharan Africa and South Asia. Screening uptake was lower for women who had no primary care provider, were in a traditional fee-for service model of primary care, had a male physician, had an internationally trained physician, resided in a low income neighbourhood, and entered Canada under the family class of immigration. Religion may play a role in screening uptake, however, the variation in rates by regions of origin, immigration class, and access to primary care providers alludes to confluence of socio-demographic, cultural beliefs and practices, immigration trajectories and system level factors. Facilitating access for immigrant women to regular primary care providers, particularly female providers and enrollment in primary care models could enhance screening uptake. Copyright © 2017 Elsevier Inc. All rights reserved.

Adolescent Risk Screening Instruments for Primary Care: An Integrative Review Utilizing the Donabedian Framework.

PubMed

Hiott, Deanna B; Phillips, Shannon; Amella, Elaine

2017-07-31

Adolescent risk-taking behavior choices can affect future health outcomes. The purpose of this integrative literature review is to evaluate adolescent risk screening instruments available to primary care providers in the United States using the Donabedian Framework of structure, process, and outcome. To examine the literature concerning multidimensional adolescent risk screening instruments available in the United States for use in the primary care setting, library searches, ancestry searches, and Internet searches were conducted. Library searches included a systematic search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Academic Search Premier, Health Source Nursing Academic Ed, Medline, PsycINFO, the Psychology and Behavioral Sciences Collection, and PubMed databases with CINAHL headings using the following Boolean search terms: "primary care" and screening and pediatric. Criteria for inclusion consisted of studies conducted in the United States that involved broad multidimensional adolescent risk screening instruments for use in the pediatric primary care setting. Instruments that focused solely on one unhealthy behavior were excluded, as were developmental screens and screens not validated or designed for all ages of adolescents. In all 25 manuscripts reviewed, 16 screens met the inclusion criteria and were included in the study. These 16 screens were examined for factors associated with the Donabedian structure-process-outcome model. This review revealed that many screens contain structural issues related to cost and length that inhibit provider implementation in the primary care setting. Process limitations regarding the report method and administration format were also identified. The Pediatric Symptom Checklist was identified as a free, short tool that is valid and reliable.
Survival analysis using primary care electronic health record data: A systematic review of the literature.

PubMed

Hodgkins, Adam Jose; Bonney, Andrew; Mullan, Judy; Mayne, Darren John; Barnett, Stephen

2018-01-01

An emerging body of research involves observational studies in which survival analysis is applied to data obtained from primary care electronic health records (EHRs). This systematic review of these studies examined the utility of using this approach. An electronic literature search of the Scopus, PubMed, Web of Science, CINAHL, and Cochrane databases was conducted. Search terms and exclusion criteria were chosen to select studies where survival analysis was applied to the data extracted wholly from EHRs used in primary care medical practice. A total of 46 studies that met the inclusion criteria for the systematic review were examined. All were published within the past decade (2005-2014) with a majority ( n = 26, 57%) being published between 2012 and 2014. Even though citation rates varied from nil to 628, over half ( n = 27, 59%) of the studies were cited 10 times or more. The median number of subjects was 18,042 with five studies including over 1,000,000 patients. Of the included studies, 35 (76%) were published in specialty journals and 11 (24%) in general medical journals. The many conditions studied largely corresponded well with conditions important to general practice. Survival analysis applied to primary care electronic medical data is a research approach that has been frequently used in recent times. The utility of this approach was demonstrated by the ability to produce research with large numbers of subjects, across a wide range of conditions and with the potential of a high impact. Importantly, primary care data were thus available to inform primary care practice.
Pediatric primary care psychologists' reported level of integration, billing practices, and reimbursement frequency.

PubMed

Riley, Andrew R; Grennan, Allison; Menousek, Kathryn; Hoffses, Kathryn W

2018-03-01

Integration of psychological services into pediatric primary care is increasingly common, but models of integration vary with regard to their level of coordination, colocation, and integration. High-integration models may provide some distinct advantages, such as preventative care and brief consultation for subclinical behavior concerns; however, psychologists face barriers to seeking reimbursement for these services. Alternatives to traditional psychotherapy and psychological testing codes, specifically Health & Behavior (H&B) codes, have been proposed as 1 method for supporting integrated care. The aim of this study was to investigate the relationships between psychologists' reported billing practices, reimbursement rates, and model of integration in pediatric primary care. As part of a larger survey study, 55 psychologists working in pediatric primary care reported on characteristics of their practice's model of integration, billing practices, and frequency of reimbursement for consultative services. Compared with those who categorized their integrated care model as colocated, psychologists who endorsed working in integrated models reported a significantly higher usage of H&B codes and more frequent reimbursement for consultations. Overall, use of H&B codes was associated with higher reported levels of coordination and integration. Survey results showed a clear pattern of higher integration being associated with greater utilization of H&B codes and better reimbursement for consultation activities. These results underscore the importance of establishing and maintaining billing and reimbursement systems that adequately support integrated care. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
Cost Implications of Primary Versus Revision Surgery in Adult Spinal Deformity.

PubMed

Qureshi, Rabia; Puvanesarajah, Varun; Jain, Amit; Kebaish, Khaled; Shimer, Adam; Shen, Francis; Hassanzadeh, Hamid

2017-08-01

Adult spinal deformity (ASD) is an important problem to consider in the elderly. Although studies have examined the complications of ASD surgery and have compared functional and radiographic results of primary surgery versus revision, no studies have compared the costs of primary procedures with revisions. We assessed the in-hospital costs of these 2 surgery types in patients with ASD. The PearlDiver Database, a database of Medicare records, was used in this study. Mutually exclusive groups of patients undergoing primary or revision surgery were identified. Patients in each group were queried for age, sex, and comorbidities. Thirty-day readmission rates, 30-day and 90-day complication rates, and postoperative costs of care were assessed with multivariate analysis. For analyses, significance was set at P < 0.001. The average reimbursement of the primary surgery cohort was $57,078 ± $30,767. Reimbursement of revision surgery cohort was $52,999 ± $27,658. The adjusted difference in average costs between the 2 groups is $4773 ± $1069 (P < 0.001). The 30-day and 90-day adjusted difference in cost of care when sustaining any of the major medical complications in primary surgery versus revision surgery was insignificant. Patients undergoing primary and revision corrective procedures for ASD have similar readmission rates, lengths of stays, and complication rates. Our data showed a higher cost of primary surgery compared with revision surgery, although costs of sustaining postoperative complications were similar. This finding supports the decision to perform revision procedures in patients with ASD when indicated because neither outcomes nor costs are a hindrance to correction. Copyright © 2017 Elsevier Inc. All rights reserved.
[Autonomy and health needs in the systematization of nursing assistance under the optics of the primary care].

PubMed

Barros, Débora Gomes; Chiesa, Anna Maria

2007-12-01

Given recent changes in the organization of the primary health care in Brazil, it is necessary to reflect on the contributions of nursing care. This article aims to review the concepts of autonomy and health needs and its applications in different proposals for the systematization of the nursing care. It is a literature review on systematization of the nursing assistance, autonomy and health needs in databases LILACS and BDENF. The most relevant results indicate that autonomy incorporates aspects professional and patient's that are sustained by their respective categories. About needs we found that tracks biological needs and social needs, which intersect with the psychological to cover biopsychosocial needs. It was found that the application of the concepts was not present in classification systems of nursing. However, they were more related to International Classification of Nursing Practice (ICNP) and International Classification of Nursing Practice in Collective Heath (ICNPCH) projects.
Effective strategies for prevention, control, and treatment of obesity in primary health care setting for adolescents, adults, and elderly people: A protocol for systematic review and meta-analysis.

PubMed

Marques, Emanuele Souza; Leite, Tatiana Henriques; Azeredo, Catarina Machado; Cunha, Diana Barbosa; Verly Júnior, Eliseu

2018-06-01

It is unquestionable that obesity is a global epidemic and one of the main public health problems in the world. The management of obesity in Primary Health Care has an important role if being considered the magnitude and serious consequence of this problem. Despite this, there is no effective standard protocol for the treatment of this disease. Studies that synthesize and assess the effectiveness of strategies for prevention, control, and treatment of obesity in Primary Health Care setting are still scarce. The objective of this study is review and synthesize study evidence for obesity management strategies among adolescents, adults and elderly developed at the Primary Health Care worldwide. Seven electronic databases (Medline, Lilacs, Embase, Psycinfo, Cochrane, WHOLIS and Open Gray) will be searched with no date limit for identification of clinical trials examining the effectiveness of prevention, control and treatment of obesity in Primary Health Care. As primary outcome will be changes in body weight. As secondary outcomes will be body mass index, body adiposity, waist circumference, and waist-hip ratio. Two independent authors will perform the selection of studies, data extraction, and the assessment of risk of bias. The results will be published in a peer-reviewed journal. This systematic review will be first to synthesize scientific evidence for obesity management strategies at Primary Health Care among adolescents, adults, and elderly. The review will benefit healthcare professionals and policymakers. Ethical approval is not required in this study because the data used include peer-reviewed publications, which do not comprise any information that could identify subjects. PROSPERO (CRD42018092416).
Barriers and facilitators in the integration of oral health into primary care: a scoping review.

PubMed

Harnagea, Hermina; Couturier, Yves; Shrivastava, Richa; Girard, Felix; Lamothe, Lise; Bedos, Christophe Pierre; Emami, Elham

2017-09-25

This scoping study has been conducted to map the literature and provide a descriptive synthesis on the barriers and facilitators of the integration of oral health into primary care. Grounded in the Rainbow conceptual model and using the Levac et al six-stage framework, we performed a systematic search of electronic databases, organisational websites and grey literature from 1978 to April 2016. All publications with a focus on the integration of oral health into primary care were included except commentaries and editorials. Thematic analyses were performed to synthesise the results. From a total of 1619 citations, 58 publications were included in the review. Barrier-related themes included: lack of political leadership and healthcare policies; implementation challenges; discipline-oriented education; lack of continuity of care and services and patients' oral healthcare needs. The facilitators of integration were supportive policies and resources allocation, interdisciplinary education, collaborative practices between dental and other healthcare professionals, presence of local strategic leaders and geographical proximity. This work has advanced the knowledge on the barriers and facilitators at each integration domain and level, which may be helpful if the healthcare organisations decide to integrate oral health and dental services into primary care. The scoping review findings could be useful for both dental and medical workforce and allied primary healthcare providers. They could also guide the development of healthcare policies that support collaborative practices and patient-centred care in the field of primary care. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Primary and community care workforce planning and development.

PubMed

Hurst, Keith

2006-09-01

This article reports a study that provided primary and community care managers with information, allowing them to: (a) evaluate the size and mix of their workforce; and (b) develop knowledgeable and skilled teams to meet the demands of growing and changing services. Primary and community care services are growing in the United Kingdom, but workforce planning and development, despite their wide-ranging cost and quality implications, have not received the same attention. Indeed, most primary and community care workforce planning and development issues are universal. Demand 1-1 side workforce planning is concerned not only with the number, but also with staff mix; but how these autonomous and isolated practitioners spend their time is unique. The other side of the equation, workforce supply, raises many recruitment and retention challenges for managers in many countries. Any country's main workforce planning methods apply equally well to primary care, but each is flawed. A second, main problem is that the methods lead to fragmented services, whereas modern workforce planning methods should be multidisciplinary. Consequently, it has never been more important for managers to have data and algorithms to develop appropriate care teams. A large and versatile workforce database, profiling 304 English primary care trusts using demographic, socio-economic, mortality, morbidity, staffing and performance workforce-related variables, compiled in 2002 and updated yearly, is described. Data were supplemented with a systematic literature review leading to a 340-item annotated bibliography; and qualitative interviews with managers. Workforce size and mix are historical and irrational at best. Moreover, the number of variables that influence staffing is growing, thereby complicating workforce planning. Evaluating and adjusting the size and mix of teams using empirically determined community demand and performance variables based on the area's socio-economic characteristics is feasible.
Databases in the Area of Pharmacogenetics

PubMed Central

Sim, Sarah C.; Altman, Russ B.; Ingelman-Sundberg, Magnus

2012-01-01

In the area of pharmacogenetics and personalized health care it is obvious that databases, providing important information of the occurrence and consequences of variant genes encoding drug metabolizing enzymes, drug transporters, drug targets, and other proteins of importance for drug response or toxicity, are of critical value for scientists, physicians, and industry. The primary outcome of the pharmacogenomic field is the identification of biomarkers that can predict drug toxicity and drug response, thereby individualizing and improving drug treatment of patients. The drug in question and the polymorphic gene exerting the impact are the main issues to be searched for in the databases. Here, we review the databases that provide useful information in this respect, of benefit for the development of the pharmacogenomic field. PMID:21309040
Patients' preferences for primary health care - a systematic literature review of discrete choice experiments.

PubMed

Kleij, Kim-Sarah; Tangermann, Ulla; Amelung, Volker E; Krauth, Christian

2017-07-11

Primary care is a key element of health care systems and addresses the main health problems of the population. Due to the demographic change, primary care even gains in importance. The knowledge of the patients' preferences can help policy makers as well as physicians to set priorities in their effort to make health care delivery more responsive to patients' needs. Our objective was to describe which aspects of primary care were included in preference studies and which of them were the most preferred aspects. In order to elicit the preferences for primary care, a systematic literature search was conducted. Two researchers searched three electronic databases (PubMed, Scopus, and PsycINFO) and conducted a narrative synthesis. Inclusion criteria were: focus on primary health care delivery, discrete choice experiment as elicitation method, and studies published between 2006 and 2015 in English language. We identified 18 studies that elicited either the patients' or the population's preferences for primary care based on a discrete choice experiment. Altogether the studies used 16 structure attributes, ten process attributes and four outcome attributes. The most commonly applied structure attribute was "Waiting time till appointment", the most frequently used process attribute was "Shared decision making / professional's attention paid to your views". "Receiving the 'best' treatment" was the most commonly applied outcome attribute. Process attributes were most often the ones of highest importance for patients or the population. The attributes and attribute levels used in the discrete choice experiments were identified by literature research, qualitative research, expert interviews, or the analysis of policy documents. The results of the DCE studies show different preferences for primary health care. The diversity of the results may have several reasons, such as the method of analysis, the selection procedure of the attributes and their levels or the specific research question of the study. As the results of discrete choice experiments depend on many different factors, it is important for a better comprehensibility of the studies to transparently report the steps undertaken in a study as well as the interim results regarding the identification of attributes and levels.
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.
Gender Differences in the Incidence of Depression Among Immigrants and Natives in Aragón, Spain.

PubMed

Esmeyer, E M; Magallón-Botaya, R; Lagro-Janssen, A L M

2017-02-01

Knowledge of depression among immigrants within Spanish primary care is limited. This database study investigates the incidence of depressive disorders among immigrants and natives within primary care in Aragón (Spain). Participants were patients registered in an electronic record register, aged above 20 years diagnosed with depression. Incidence of depression was calculated and compared per continent of origin, gender and age with the Mann-Whitney U test and the Kruskal-Wallis test. The population consisted of 11,088 patients with depression of whom 93.0 % natives and 7.0 % immigrants. Incidence of depression amongst male immigrants was lower than amongst male natives (OR 0.80). Eastern European males showed the lowest incidence 4.1 (3.5-5.3). The gender difference in incidence was larger in immigrants than in natives (OR 3.4 vs. 2.7). Due to male immigrants the incidence of depression within primary care is lower among immigrants. Equal care should be provided to patients of both genders and all origin.
[Social constructionism in primary health care: an integrative review].

PubMed

Cadoná, Eliane; Scarparo, Helena

2015-09-01

This study sets out to analyze scientific articles in order to investigate how researchers in the area of Social Constructionism define "health" in Primary Health Care. An integrative review of the literature was conducted along with a decision to concentrate on those works with narrative experiences and research studies. The database researched was the Brazilian Virtual Health Library, with experiences in the scope of Primary Health Care. The effectiveness of this step resulted in 12 articles. Data were analyzed and discussed based on the perspectives of social constructionism, which generated two central themes. They were: citizenship exercises - promoting health in collective spaces; health practices - overcoming the dichotomies and absolute truths. This study revealed the relevance of the notion of shared responsibility on meanings of health contained in the texts analyzed. The researchers claim that it is possible to expand health practices into collective action to facilitate ongoing dialogue between health users and workers. However, the dominance of biomedical discourse is criticized by the researchers, because that paradigm still promotes practices of care focused on illness.
Feasibility of automatic evaluation of clinical rules in general practice.

PubMed

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

2017-04-01

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

PubMed

de Oliveira, Claire; Wijeysundera, Harindra C; Tobe, Sheldon W; Lum-Kwong, Margaret Moy; Von Sychowski, Shirley; Wang, Xuesong; Tu, Jack V; Krahn, Murray D

2012-01-01

Hypertension is suboptimally treated in primary care settings. We evaluated the cost-effectiveness of the Heart and Stroke Foundation of Ontario's Hypertension Management Initiative (HMI), an interdisciplinary, evidence-informed chronic disease management model for primary care that focuses on improving blood pressure management and control by primary care providers and patients according to clinical best practice guidelines. The perspective of our analysis was that of the Ontario Ministry of Health and Long-Term Care with a lifetime horizon and 5% annual discount rate. Using data from a prospective cohort study from the HMI, we created two matched groups: pre-HMI (standard care), and post-HMI (n = 1720). For each patient, we estimated the 10-year risk of cardiovascular disease (CVD) using the Framingham risk equation and life expectancy from life tables. Long-term health care costs incurred with physician visits, acute and chronic care hospitalizations, emergency department visits, same-day surgeries, and medication use were determined through linkage to administrative databases, using a bottom-up approach. The HMI intervention was associated with significant reductions in systolic blood pressure (126 mmHg vs 134 mmHg with standard care; P-value < 0.001). These improvements were associated with a reduction in the 10-year risk of CVD (9.5% risk vs 10.7% in standard care; P-value < 0.001) and a statistically significant improvement in discounted life expectancy (9.536 years vs 9.516 in standard care; P-value < 0.001). The HMI cohort had a discounted mean lifetime cost of $22,884 CAD vs $22,786 CAD for standard care, with an incremental cost-effectiveness ratio of $4939 CAD per life-year gained. We found that the HMI is a cost-effective means of providing evidence-informed, chronic disease management in primary care to patients with hypertension.
Can antiviral treatment for hepatitis C be safely and effectively delivered in primary care?: a narrative systematic review of the evidence base.

PubMed

Brew, Iain F; Butt, Christine; Wright, Nat

2013-12-01

The burden of hepatitis C (HCV) treatment is growing, as is the political resolve to tackle the epidemic. Primary care will need to work more closely with secondary care to succeed in reducing the prevalence of chronic HCV. To identify research relating to the provision of antiviral treatment for HCV in primary care. A narrative systematic review of six databases. Method Medline, Embase, Cinahl, PsycINFO, Web of Science, and Cochrane were searched. Relevant journals were searched by hand for articles to be included in the review. Reference lists of relevant papers were reviewed and full-text papers were retrieved for those deemed to potentially fulfil the inclusion criteria of the review. A total of 683 abstracts led to 77 full-text articles being retrieved, of which 16 were finally included in the review. An evidence base emerged, highlighting that community-based antiviral treatment provision is feasible and can result in clinical outcomes comparable to those achieved in hospital outpatient settings. Such provision can be in mainstream general practice, at community addiction centres, or in prisons. GPs must be trained before offering such a service and there is also a need for ongoing specialist supervision of primary care practice. Such training and supervision can be delivered by teleconference, although, even with such ready availability of training and supervision, only a minority of GPs are likely to want to provide antiviral treatment. There is emerging evidence supporting the effectiveness of antiviral treatment provision for patients with chronic hepatitis C in a wide variety of primary care and wider community settings. Training and ongoing supervision of primary care practitioners by specialists is a prerequisite. There is an opportunity through future research activity to evaluate typologies of patients who would be best served by primary care-based treatment and those for whom hospital-based outpatient treatment would be most appropriate.
Integrated Primary Care Readiness and Behaviors Scale: Development and validation in behavioral health professionals.

PubMed

Blaney, Cerissa L; Redding, Colleen A; Paiva, Andrea L; Rossi, Joseph S; Prochaska, James O; Blissmer, Bryan; Burditt, Caitlin T; Nash, Justin M; Bayley, Keri Dotson

2018-03-01

Although integrated primary care (IPC) is growing, several barriers remain. Better understanding of behavioral health professionals' (BHPs') readiness for and engagement in IPC behaviors could improve IPC research and training. This study developed measures of IPC behaviors and stage of change. The sample included 319 licensed, practicing BHPs with a range of interests and experience with IPC. Sequential measurement development procedures, with split-half cross-validation were conducted. Exploratory principal components analyses (N = 152) and confirmatory factor analyses (N = 167) yielded a 12-item scale with 2 factors: consultation/practice management (CPM) and intervention/knowledge (IK). A higher-order Integrated Primary Care Behavior Scale (IPCBS) model showed good fit to the data, and excellent internal consistencies. The multivariate analysis of variance (MANOVA) on the IPCBS demonstrated significant large-sized differences across stage and behavior groups. The IPCBS demonstrated good psychometric properties and external validation, advancing research, education, and training for IPC practice. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
Approach to traumatic hand injuries for primary care physicians.

PubMed

Cheung, Kevin; Hatchell, Alexandra; Thoma, Achilleas

2013-06-01

To review the initial management of common traumatic hand injuries seen by primary care physicians. Current clinical evidence and literature identified through MEDLINE electronic database searches was reviewed. Expert opinion was used to supplement recommendations for areas with little evidence. Primary care physicians must routinely manage patients with acute traumatic hand injuries. In the context of a clinical case, we review the assessment, diagnosis, and initial management of common traumatic hand injuries. The presentation and management of nail bed injuries, fingertip amputations, mallet fingers, hand fractures, tendon lacerations, bite injuries, and infectious tenosynovitis will also be discussed. The principles of managing traumatic hand injuries involve the reduction and immobilization of fractures, obtaining post-reduction x-ray scans, obtaining soft tissue coverage, preventing and treating infection, and ensuring tetanus prophylaxis. Proper assessment and management of traumatic hand injuries is essential to prevent substantial long-term morbidity in this generally otherwise healthy population. Early recognition of injuries that require urgent or emergent referral to a hand surgeon is critical.
The Impact of Discharge Disposition on Episode-of-Care Reimbursement After Primary Total Hip Arthroplasty.

PubMed

Sabeh, Karim G; Rosas, Samuel; Buller, Leonard T; Roche, Martin W; Hernandez, Victor H

2017-10-01

Total joint arthroplasty (TJA) accounts for more Medicare expenditure than any other inpatient procedure. The Comprehensive Care for Joint Replacement model was introduced to decrease cost and improve quality in TJA. The largest portion of episode-of-care costs occurs after discharge. This study sought to quantify the cost variation of primary total hip arthroplasty (THA) according to discharge disposition. The Medicare and Humana claims databases were used to extract charges and reimbursements to compare day-of-surgery and 91-day postoperative costs simulating episode-of-care reimbursements. Of the patients who underwent primary THA, 257,120 were identified (204,912 from Medicare and 52,208 from Humana). Patients were stratified by discharge disposition: home with home health, skilled nursing facility, or inpatient rehabilitation facility. There is a significant difference in the episode-of-care costs according to discharge disposition, with discharge to an inpatient rehabilitation facility the most costly and discharge to home the least costly. Postdischarge costs represent a sizeable portion of the overall expense in THA, and optimizing patients to allow safe discharge to home may help reduce the cost of THA. Copyright © 2017 Elsevier Inc. All rights reserved.
Text messaging in health care: a systematic review of impact studies.

PubMed

Yeager, Valerie A; Menachemi, Nir

2011-01-01

Studies suggest text messaging is beneficial to health care; however, no one has synthesized the overall evidence on texting interventions. In response to this need, we conducted a systematic review of the impacts of text messaging in health care. PubMed database searches and subsequent reference list reviews sought English-language, peer-reviewed studies involving text messaging in health care. Commentaries, conference proceedings, and feasibilities studies were excluded. Data was extracted using an article coding sheet and input into a database for analysis. Of the 61 papers reviewed, 50 articles (82%) found text messaging had a positive effect on the primary outcome. Average sample sizes in articles reporting positive findings (n=813) were significantly larger than those that did not find a positive impact (n=178) on outcomes (p = 0.032). Articles were categorized into focal groups as follows: 27 articles (44.3%) investigated the impact of texting on disease management, 24 articles (39.3%) focused texting's impact to public health related outcomes, and 10 articles (16.4%) examined texting and its influence on administrative processes. Articles in focal groups differed by the purpose of the study, direction of the communication, and where they were published, but not in likelihood of reporting a positive impact from texting. Current evidence indicates that text messaging health care interventions are largely beneficial clinically, in public health related uses, and in terms of administrative processes. However, despite the promise of these findings, literature gaps exist, especially in primary care settings, across geographic regions and with vulnerable populations.

Quality Primary Care and Family Planning Services for LGBT Clients: A Comprehensive Review of Clinical Guidelines.

PubMed

Klein, David A; Malcolm, Nikita M; Berry-Bibee, Erin N; Paradise, Scott L; Coulter, Jessica S; Keglovitz Baker, Kristin; Schvey, Natasha A; Rollison, Julia M; Frederiksen, Brittni N

2018-04-01

LGBT clients have unique healthcare needs but experience a wide range of quality in the care that they receive. This study provides a summary of clinical guideline recommendations related to the provision of primary care and family planning services for LGBT clients. In addition, we identify gaps in current guidelines, and inform future recommendations and guidance for clinical practice and research. PubMed, Cochrane, and Agency for Healthcare Research and Quality electronic bibliographic databases, and relevant professional organizations' websites, were searched to identify clinical guidelines related to the provision of primary care and family planning services for LGBT clients. Information obtained from a technical expert panel was used to inform the review. Clinical guidelines meeting the inclusion criteria were assessed to determine their alignment with Institute of Medicine (IOM) standards for the development of clinical practice guidelines and content relevant to the identified themes. The search parameters identified 2,006 clinical practice guidelines. Seventeen clinical guidelines met the inclusion criteria. Two of the guidelines met all eight IOM criteria. However, many recommendations were consistent regarding provision of services to LGBT clients within the following themes: clinic environment, provider cultural sensitivity and awareness, communication, confidentiality, coordination of care, general clinical principles, mental health considerations, and reproductive health. Guidelines for the primary and family planning care of LGBT clients are evolving. The themes identified in this review may guide professional organizations during guideline development, clinicians when providing care, and researchers conducting LGBT-related studies.
Continued Inpatient Care After Primary Total Knee Arthroplasty Increases 30-Day Post-Discharge Complications: A Propensity Score-Adjusted Analysis.

PubMed

McLawhorn, Alexander S; Fu, Michael C; Schairer, William W; Sculco, Peter K; MacLean, Catherine H; Padgett, Douglas E

2017-09-01

Discharge destination, either home or skilled care facility, after total knee arthroplasty (TKA) may be associated with significant variation in postacute care outcomes. The purpose of this study was to characterize the 30-day postdischarge outcomes after primary TKA relative to discharge destination. All primary unilateral TKAs performed for osteoarthritis from 2011-2014 were identified in the National Surgical Quality Improvement Program database. Propensity scores based on predischarge characteristics were used to adjust for selection bias in discharge destination. Propensity-adjusted multivariable logistic regressions were used to examine associations between discharge destination and postdischarge complications. Among 101,256 primary TKAs identified, 70,628 were discharged home and 30,628 to skilled care facilities. Patients discharged to facilities were more frequently were female, older, higher body mass index class, higher Charlson comorbidity index and American Society of Anesthesiologists scores, had predischarge complications, received general anesthesia, and classified as nonindependent preoperatively. Propensity adjustment accounted for this selection bias. Patients discharged to skilled care facilities after TKA had higher odds of any major complication (odds ratio = 1.25; 95% confidence interval, 1.13-1.37) and readmission (odds ratio = 1.81; 95% confidence interval, 1.50-2.18). Skilled care was associated with increased odds for respiratory, septic, thromboembolic, and urinary complications. Associations with death, cardiac, and wound complications were not significant. After controlling for predischarge characteristics, discharge to skilled care facilities vs home after primary TKA is associated with higher odds of numerous complications and unplanned readmission. These results support coordination of care pathways to facilitate home discharge after hospitalization for TKA whenever possible. Copyright © 2017 Elsevier Inc. All rights reserved.
Development and deployment of a health information system in transitional countries (croatian experience).

PubMed

Stevanovic, Ranko; Pristas, Ivan; Ivicevic Uhernik, Ana; Stanic, Arsen

2005-01-01

Croatian Primary Health Care Information System pilot project, conducted between 2001 and 2003, aimed to develop and deploy a health information system based on the latest technologies which would improve the quality of primary health care and rationalise the consumption. 60 primary health care teams (physician and nurse) were equipped with PCs and connected via central server to the main national health insurer, state treasury and public health institute. Developed information system enabled rapid retrieval of documents, replacement of manual data input and a real-time insight into needed information as well as prompt interventions within the system. The project also introduced electronic smart cards for physicians and nurses, so that at each medical check-up the information system verified both the ensuree's and the physician's or nurse's status and rights.Based on the experiences from the pilot project, plan has been made for comprehensive health information system at national level which would connect primary health care teams, hospitals, laboratories, dentistries, health insurance companies, state treasury, public health institutes and electronic health records database. Its major goals are more rapid diagnostics, accuracy in prescribing therapy, standardisation of the good practice as well as better utilisation of capacities, shorter waiting times and shorter stays in hospitals, which would lead to improvement in overall health care quality and better control over the health care consumption. Estimated 5-year investment for installing such system would be 125 million EUR. However, information system could save substantially more and yield a return of investment in only two years.As information system for primary health care should be a strategic component of every health care reform and development plan, we can recommend our model, based on the results of the pilot project, to other transitional countries.
Quality of care and volume for patients with diabetes mellitus in the primary care setting: A population based retrospective cohort study.

PubMed

Wong, Carlos K H; Fung, Colman S C; Kung, Kenny; Wan, Eric Y F; Yu, Esther Y T; Chan, Anca K C; Lam, Cindy L K

2016-10-01

To examine the association of patient volume with quality of diabetes care in the primary care setting. We analyzed population-based data from Hospital Authority administrative database using a Hong Kong representative sample of 187,031 diabetic patients managed in 74 primary care general outpatient clinics between 04/2011 and 03/2012. We assessed the associations between annual clinic-based patient volume and quality of care in terms of adherence to care criteria of process (HbA1c test, renal function test, full lipid profile, urine protein analysis, diabetic retinopathy screening, and appropriate drug prescription) and clinical outcomes (HbA1c⩽7%, BP⩽130/80mmHg, LDL-C⩽2.6mmol/L) of care criteria, with and without adjustment for patient and clinic characteristics. Patient volume was associated with three of seven process of care criteria; however, when compared to clinics in higher volume quartiles, those in lowest-volume quartile had more odds of HbA1c test (odds ratios (OR): 0.781, 0.655 and 0.646 for quartile from 2 to 4, respectively), renal function test (OR: 0.357, 0.367 and 0.590 for quartile from 2 to 4, respectively), and full lipid profile test (OR: 0.508, 0.612 and 0.793 for quartile from 2 to 4, respectively). There was no significant association between patient volume and the standards of achieving of HbA1c, BP and LDL-C outcome targets. Disparities in volume and quality of diabetes care were observed in public primary care setting. Lower patient volumes at clinic level were associated with greater adherence to three process criteria but a volume-outcome association was not present. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
What drives the prescribing of growth hormone preparations in England? Prices versus patient preferences

PubMed Central

Chapman, Stephen R; Fitzpatrick, Raymond W; Aladul, Mohammed I

2017-01-01

Objective The patent expiry of a number of biological medicines and the advent of biosimilars raised the expectations of healthcare commissioners that biosimilars would reduce the high cost of these medicines and produce potential savings to the NHS. We aimed to examine the prescribing pattern of different growth hormone preparations (ready to use and reconstitution requiring) in primary and secondary care in England to determine relative rates of decrease or increase and identify the possible factors influencing prescribing following the introduction of biosimilar growth hormone in 2008. Design Longitudinal observational study. Setting and data sources Primary care prescribing cost and volume data was derived from the NHS business services authority website, and for secondary care from the DEFINE database, between April 2011 and December 2015. Outcomes Quarterly prescribing analysis to examine trends and measure the relationship between usage and price. Results Expenditure and usage of growth hormone in primary care decreased by 17.91% and 7.29%, respectively, whereas expenditure and usage in secondary care increased by 68.41% and 100%, respectively, between April 2011 and December 2015. The usage of reconstitution requiring products significantly declined in primary care (R²=0.9292) and slightly increased in use in secondary care (R²=0.139). In contrast, the usage of ready-to-use products significantly increased in use in primary (R²=0.7526) and secondary care (R²=0.9633), respectively. Weak or no correlation existed between the usage and price of growth hormone preparations in primary and secondary care. Conclusions The price of growth hormone products was not the key factor influencing the prescribing of the biological medicines. The main driver for specific product selection was the ease of use and the number of steps in dose preparation. Prescribers appear to be taking into account patient preferences rather than cost in their prescribing decisions. PMID:28400458
What drives the prescribing of growth hormone preparations in England? Prices versus patient preferences.

PubMed

Chapman, Stephen R; Fitzpatrick, Raymond W; Aladul, Mohammed I

2017-04-11

The patent expiry of a number of biological medicines and the advent of biosimilars raised the expectations of healthcare commissioners that biosimilars would reduce the high cost of these medicines and produce potential savings to the NHS. We aimed to examine the prescribing pattern of different growth hormone preparations (ready to use and reconstitution requiring) in primary and secondary care in England to determine relative rates of decrease or increase and identify the possible factors influencing prescribing following the introduction of biosimilar growth hormone in 2008. Longitudinal observational study. Primary care prescribing cost and volume data was derived from the NHS business services authority website, and for secondary care from the DEFINE database, between April 2011 and December 2015. Quarterly prescribing analysis to examine trends and measure the relationship between usage and price. Expenditure and usage of growth hormone in primary care decreased by 17.91% and 7.29%, respectively, whereas expenditure and usage in secondary care increased by 68.41% and 100%, respectively, between April 2011 and December 2015. The usage of reconstitution requiring products significantly declined in primary care (R²=0.9292) and slightly increased in use in secondary care (R²=0.139). In contrast, the usage of ready-to-use products significantly increased in use in primary (R²=0.7526) and secondary care (R²=0.9633), respectively. Weak or no correlation existed between the usage and price of growth hormone preparations in primary and secondary care. The price of growth hormone products was not the key factor influencing the prescribing of the biological medicines. The main driver for specific product selection was the ease of use and the number of steps in dose preparation. Prescribers appear to be taking into account patient preferences rather than cost in their prescribing decisions. 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/.
Practice nursing in Australia: A review of education and career pathways

PubMed Central

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

2009-01-01

Background Nurses in Australia are often not educated in their pre registration years to meet the needs of primary care. Careers in primary care may not be as attractive to nursing graduates as high-tech settings such as intensive or acute care. Yet, it is in primary care that increasingly complex health problems are managed. The Australian government has invested in incentives for general practices to employ practice nurses. However, no policy framework has been developed for practice nursing to support career development and post-registration education and training programs are developed in an ad hoc manner and are not underpinned by core professional competencies. This paper reports on a systematic review undertaken to establish the available evidence on education models and career pathways with a view to enhancing recruitment and retention of practice nurses in primary care in Australia. Methods Search terms describing education models, career pathways and policy associated with primary care (practice) nursing were established. These search terms were used to search electronic databases. The search strategy identified 1394 citations of which 408 addressed one or more of the key search terms on policy, education and career pathways. Grey literature from the UK and New Zealand internet sites were sourced and examined. The UK and New Zealand Internet sites were selected because they have well established and advanced developments in education and career pathways for practice nurses. Two reviewers examined titles, abstracts and studies, based on inclusion and exclusion criteria. Disagreement between the reviewers was resolved by consensus or by a third reviewer. Results Significant advances have been made in New Zealand and the UK towards strengthening frameworks for primary care nursing education and career pathways. However, in Australia there is no policy at national level prepare nurses to work in primary care sector and no framework for education or career pathways for nurses working in that sector. Conclusion There is a need for national training standards and a process of accreditation for practice nursing in Australia to support the development of a responsive and sustainable nursing workforce in primary care and to provide quality education and career pathways. PMID:19473493
Scrutinizing screening: a critical interpretive review of primary care provider perspectives on mammography decision-making with average-risk women.

PubMed

Siedlikowski, Sophia; Ells, Carolyn; Bartlett, Gillian

2018-01-01

A decision to undertake screening for breast cancer often takes place within the primary care setting, but current controversies such as overdiagnosis and inconsistent screening recommendations based on evolving evidence render this a challenging process, particularly for average-risk women. Given the responsibility of primary care providers in counseling women in this decision-making process, it is important to understand their thoughts on these controversies and how they manage uncertainty in their practice. To review the perspectives and approaches of primary care providers regarding mammography decision-making with average-risk women. This study is a critical interpretive review of peer-review literature that reports primary care provider perspectives on mammography screening decision-making. Ovid MEDLINE®, Ovid PsycInfo, and Scopus databases were searched with dates from 2002 to 2017 using search terms related to mammography screening, uncertainty, counseling, decision-making, and primary health care providers. Nine articles were included following a review process involving the three authors. Using an inductive and iterative approach, data were grouped into four thematic categories: (1) perceptions on the effectiveness of screening, screening initiation age, and screening frequency; (2) factors guiding primary care providers in the screening decision-making process, including both provider and patient-related factors, (3) uncertainty faced by primary care providers regarding guidelines and screening discussions with their patients; and (4) informed decision-making with average-risk women, including factors that facilitate and hinder this process. The discussion of results addresses several factors about the diversity of perspectives and practices of physicians counseling average-risk women regarding breast cancer screening. This has implications for the challenge of understanding and explaining evidence, what should be shared with average-risk women considering screening, the forms of knowledge that physicians value to guide screening decision-making, and the consent process for population-based screening initiatives. Within the data, there was little attention placed on how physicians coped with uncertainty in practice. Given the dual responsibility of physicians in caring for both individuals and the larger population, further research should probe more deeply into how they balance their duties to individual patients with those to the larger population they serve.
Practice nursing in Australia: A review of education and career pathways.

PubMed

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

2009-05-27

Nurses in Australia are often not educated in their pre registration years to meet the needs of primary care. Careers in primary care may not be as attractive to nursing graduates as high-tech settings such as intensive or acute care. Yet, it is in primary care that increasingly complex health problems are managed. The Australian government has invested in incentives for general practices to employ practice nurses. However, no policy framework has been developed for practice nursing to support career development and post-registration education and training programs are developed in an ad hoc manner and are not underpinned by core professional competencies. This paper reports on a systematic review undertaken to establish the available evidence on education models and career pathways with a view to enhancing recruitment and retention of practice nurses in primary care in Australia. Search terms describing education models, career pathways and policy associated with primary care (practice) nursing were established. These search terms were used to search electronic databases. The search strategy identified 1394 citations of which 408 addressed one or more of the key search terms on policy, education and career pathways. Grey literature from the UK and New Zealand internet sites were sourced and examined. The UK and New Zealand Internet sites were selected because they have well established and advanced developments in education and career pathways for practice nurses.Two reviewers examined titles, abstracts and studies, based on inclusion and exclusion criteria. Disagreement between the reviewers was resolved by consensus or by a third reviewer. Significant advances have been made in New Zealand and the UK towards strengthening frameworks for primary care nursing education and career pathways. However, in Australia there is no policy at national level prepare nurses to work in primary care sector and no framework for education or career pathways for nurses working in that sector. There is a need for national training standards and a process of accreditation for practice nursing in Australia to support the development of a responsive and sustainable nursing workforce in primary care and to provide quality education and career pathways.
LIS–lnterlink—connecting laboratory information systems to remote primary health–care centres via the Internet

PubMed Central

Clark, Barry; Wachowiak, Bartosz; Crawford, Ewan W.; Jakubowski, Zenon; Kabata, Janusz

1998-01-01

A pilot study was performed to evaluate the feasibility of using the Internet to securely deliver patient laboratory results, and the system has subsequently gone into routine use in Poland. The system went from design to pilot and then to live implementation within a four-month period, resulting in the LIS-Interlink software product. Test results are retrieved at regular intervals from the BioLinkTM LIS (Laboratory Information System), encrypted and transferred to a secure area on the Web server. The primary health-care centres dial into the Internet using a local-cell service provided by Polish Telecom (TP), obtain a TCP/IP address using the TP DHCP server, and perform HTTP ‘get’ and ‘post’ operations to obtain the files by secure handshaking. The data are then automatically inserted into a local SQL database (with optional printing of incoming reports)for cumulative reporting and searching functions. The local database is fully multi-user and can be accessed from different clinics within the centres by a variety of networking protocols. PMID:18924820
LIS-lnterlink-connecting laboratory information systems to remote primary health-care centres via the Internet.

PubMed

Clark, B; Wachowiak, B; Crawford, E W; Jakubowski, Z; Kabata, J

1998-01-01

A pilot study was performed to evaluate the feasibility of using the Internet to securely deliver patient laboratory results, and the system has subsequently gone into routine use in Poland. The system went from design to pilot and then to live implementation within a four-month period, resulting in the LIS-Interlink software product. Test results are retrieved at regular intervals from the BioLink(TM) LIS (Laboratory Information System), encrypted and transferred to a secure area on the Web server. The primary health-care centres dial into the Internet using a local-cell service provided by Polish Telecom (TP), obtain a TCP/IP address using the TP DHCP server, and perform HTTP 'get' and 'post' operations to obtain the files by secure handshaking. The data are then automatically inserted into a local SQL database (with optional printing of incoming reports)for cumulative reporting and searching functions. The local database is fully multi-user and can be accessed from different clinics within the centres by a variety of networking protocols.
Systematic review of scope and quality of electronic patient record data in primary care

PubMed Central

Thiru, Krish; Hassey, Alan; Sullivan, Frank

2003-01-01

Objective To systematically review measures of data quality in electronic patient records (EPRs) in primary care. Design Systematic review of English language publications, 1980-2001. Data sources Bibliographic searches of medical databases, specialist medical informatics databases, conference proceedings, and institutional contacts. Study selection Studies selected according to a predefined framework for categorising review papers. Data extraction Reference standards and measurements used to judge quality. Results Bibliographic searches identified 4589 publications. After primary exclusions 174 articles were classified, 52 of which met the inclusion criteria for review. Selected studies were primarily descriptive surveys. Variability in methods prevented meta-analysis of results. Forty eight publications were concerned with diagnostic data, 37 studies measured data quality, and 15 scoped EPR quality. Reliability of data was assessed with rate comparison. Measures of sensitivity were highly dependent on the element of EPR data being investigated, while the positive predictive value was consistently high, indicating good validity. Prescribing data were generally of better quality than diagnostic or lifestyle data. Conclusion The lack of standardised methods for assessment of quality of data in electronic patient records makes it difficult to compare results between studies. Studies should present data quality measures with clear numerators, denominators, and confidence intervals. Ambiguous terms such as “accuracy” should be avoided unless precisely defined. PMID:12750210
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.
Resource Use and Costs Associated with Coeliac Disease before and after Diagnosis in 3,646 Cases: Results of a UK Primary Care Database Analysis

PubMed Central

Violato, Mara; Gray, Alastair; Papanicolas, Irini; Ouellet, Melissa

2012-01-01

Background Despite the considerable health impact of coeliac disease (CD), reliable estimates of the impact of diagnosis on health care use and costs are lacking. Aims To quantify the volume, type and costs, in a United Kingdom primary care setting, of healthcare resources used by individuals diagnosed with CD up to ten years before and after diagnosis, and to estimate medical costs associated with CD. Methods A cohort of 3,646 CD cases and a parallel cohort of 32,973 matched controls, extracted from the General Practice Research Database (GPRD) over the period 1987–2005 were used i) to evaluate the impact of diagnosis on the average resource use and costs of cases; ii) to assess direct healthcare costs due to CD by comparing average resource use and costs incurred by cases vs. controls. Results Average annual healthcare costs per patient increased by £310 (95% CI £299, £320) after diagnosis. CD cases experienced higher healthcare costs than controls both before diagnosis (mean difference £91; 95% CI: £86, £97) and after diagnosis (mean difference £354; 95% CI: £347, £361). These differences were driven mainly by higher test and referral costs before diagnosis, and by increased prescription costs after diagnosis. Conclusions This study shows significant additional primary care costs associated with coeliac disease. It provides novel evidence that will assist researchers evaluating interventions in this area, and will challenge policymakers, clinicians, researchers and the public to develop strategies that maximise the health benefits of the resources associated with this disease. PMID:22815991
Chronic obstructive pulmonary disease self-management activation research trial (COPD-SMART): results of recruitment and baseline patient characteristics.

PubMed

Russo, Rennie; Coultas, David; Ashmore, Jamile; Peoples, Jennifer; Sloan, John; Jackson, Bradford E; Uhm, Minyong; Singh, Karan P; Blair, Steven N; Bae, Sejong

2015-03-01

To describe the recruitment methods, study participation rate, and baseline characteristics of a representative sample of outpatients with COPD eligible for pulmonary rehabilitation participating in a trial of a lifestyle behavioral intervention to increase physical activity. A patient registry was developed for recruitment using an administrative database from primary care and specialty clinics of an academic medical center in northeast Texas for a parallel group randomized trial. The registry was comprised of 5582 patients and over the course of the 30 month recruitment period 325 patients were enrolled for an overall study participation rate of 35.1%. After a 6-week COPD self-management education period provided to all enrolled patients, 305 patients were randomized into either usual care (UC; n=156) or the physical activity self-management intervention (PASM; n=149). There were no clinically significant differences in demographics, clinical characteristics, or health status indicators between the randomized groups. The results of this recruitment process demonstrate the successful use of a patient registry for enrolling a representative sample of outpatients eligible for pulmonary rehabilitation with COPD from primary and specialty care. Moreover, this approach to patient recruitment provides a model for future studies utilizing administrative databases and electronic health records. Published by Elsevier Inc.
[Accidents with biological material in health care workers in 2 primary health care areas (1990-1999)].

PubMed

Hernández Navarrete, M J; Montes Villameriel, F J; Solano Bernad, V M; Sánchez Matienzo, D; del Val García, J L; Gil Montalbán, E; Arribas Llorente, J L

2001-09-15

To find out the exposures with biological material in health care workers in primary health care, registered in the biological accidents database from Preventive Medicine Service in Miguel Servet Universitary Hospital of Zaragoza. Descriptive study of a retrospective cohort. SITE: Primary health care, Areas II and V of Zaragoza.Participants. Workers in this areas, distributed by: physician, nursing staff, auxiliary, orderly, housekeeping staff, others. Data of: workers, accident, serologic source, worker protection and vaccinal status of hepatitis B. The incidence of accidents was 26 (period 1997-1999). Most proportion of accidents were declared by nursing (78%). The highest occupational incidence was in auxiliary (63 ). In 90,1% of the cases, the accident was needlestick injury. The source was known in 67,7% of cases. The accidents occurred in hands in 96,8% of cases, and only one third of workers carried gloves. Results obtained are similar with previous studies about this event. We must insist on the need to declare these accidents, providing more information and accessibility for the declaration to worker. Moreover, we must insist on the correct application in the health care field of the standard precautions, because almost 50% of accidents are evitable, and to increase hepatitis B vaccination covertures.
Increased registration of hypertension and cancer diagnoses after the introduction of a new reimbursement system

PubMed Central

Hjerpe, Per; Boström, Kristina Bengtsson; Lindblad, Ulf; Merlo, Juan

2012-01-01

Objective To investigate the impact on ICD coding behaviour of a new case-mix reimbursement system based on coded patient diagnoses. The main hypothesis was that after the introduction of the new system the coding of chronic diseases like hypertension and cancer would increase and the variance in propensity for coding would decrease on both physician and health care centre (HCC) levels. Design Cross-sectional multilevel logistic regression analyses were performed in periods covering the time before and after the introduction of the new reimbursement system. Setting Skaraborg primary care, Sweden. Subjects All patients (n = 76 546 to 79 826) 50 years of age and older visiting 468 to 627 physicians at the 22 public HCCs in five consecutive time periods of one year each. Main outcome measures Registered codes for hypertension and cancer diseases in Skaraborg primary care database (SPCD). Results After the introduction of the new reimbursement system the adjusted prevalence of hypertension and cancer in SPCD increased from 17.4% to 32.2% and from 0.79% to 2.32%, respectively, probably partly due to an increased diagnosis coding of indirect patient contacts. The total variance in the propensity for coding declined simultaneously at the physician level for both diagnosis groups. Conclusions Changes in the healthcare reimbursement system may directly influence the contents of a research database that retrieves data from clinical practice. This should be taken into account when using such a database for research purposes, and the data should be validated for each diagnosis. PMID:23130878
Provider perceptions of an integrated primary care quality improvement strategy: The PPAQ toolkit.

PubMed

Beehler, Gregory P; Lilienthal, Kaitlin R

2017-02-01

The Primary Care Behavioral Health (PCBH) model of integrated primary care is challenging to implement with high fidelity. The Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) was designed to assess provider adherence to essential model components and has recently been adapted into a quality improvement toolkit. The aim of this pilot project was to gather preliminary feedback on providers' perceptions of the acceptability and utility of the PPAQ toolkit for making beneficial practice changes. Twelve mental health providers working in Department of Veterans Affairs integrated primary care clinics participated in semistructured interviews to gather quantitative and qualitative data. Descriptive statistics and qualitative content analysis were used to analyze data. Providers identified several positive features of the PPAQ toolkit organization and structure that resulted in high ratings of acceptability, while also identifying several toolkit components in need of modification to improve usability. Toolkit content was considered highly representative of the (PCBH) model and therefore could be used as a diagnostic self-assessment of model adherence. The toolkit was considered to be high in applicability to providers regardless of their degree of prior professional preparation or current clinical setting. Additionally, providers identified several system-level contextual factors that could impact the usefulness of the toolkit. These findings suggest that frontline mental health providers working in (PCBH) settings may be receptive to using an adherence-focused toolkit for ongoing quality improvement. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
Association between quality domains and health care spending across physician networks

PubMed Central

Rahman, Farah; Guan, Jun; Glazier, Richard H.; Brown, Adalsteinn; Bierman, Arlene S.; Croxford, Ruth; Stukel, Therese A.

2018-01-01

One of the more fundamental health policy questions is the relationship between health care quality and spending. A better understanding of these relationships is needed to inform health systems interventions aimed at increasing quality and efficiency of care. We measured 65 validated quality indicators (QI) across Ontario physician networks. QIs were aggregated into domains representing six dimensions of care: screening and prevention, evidence-based medications, hospital-community transitions (7-day post-discharge visit with a primary care physician; 30-day post-discharge visit with a primary care physician and specialist), potentially avoidable hospitalizations and emergency department (ED) visits, potentially avoidable readmissions and unplanned returns to the ED, and poor cancer end of life care. Each domain rate was computed as a weighted average of QI rates, weighting by network population at risk. We also measured overall and sector-specific per capita healthcare network spending. We evaluated the associations between domain rates, and between domain rates and spending using weighted correlations, weighting by network population at risk, using an ecological design. All indicators were measured using Ontario health administrative databases. Large variations were seen in timely hospital-community transitions and potentially avoidable hospitalizations. Networks with timely hospital-community transitions had lower rates of avoidable admissions and readmissions (r = -0.89, -0.58, respectively). Higher physician spending, especially outpatient primary care spending, was associated with lower rates of avoidable hospitalizations (r = -0.83) and higher rates of timely hospital-community transitions (r = 0.81) and moderately associated with lower readmission rates (r = -0.46). Investment in effective primary care services may help reduce burden on the acute care sector and associated expenditures. PMID:29614131
Impact of the Family Health Program on gastroenteritis in children in Bahia, Northeast Brazil: an analysis of primary care-sensitive conditions

PubMed Central

Monahan, Laura J.; Calip, Gregory S.; Novo, Patricia; Sherstinsky, Mark; Casiano, Mildred; Mota, Eduardo; Dourado, Inês

2013-01-01

In seeking to provide universal health care through its primary care-oriented Family Health Program, Brazil has attempted to reduce hospitalization rates for preventable illnesses such as childhood gastroenteritis. We measured rates of Primary Care-sensitive Hospitalizations and evaluated the impact of the Family Health Program on pediatric gastroenteritis trends in high-poverty Northeast Brazil. We analyzed aggregated municipal-level data in time-series between years 1999-2007 from the Brazilian health system payer database and performed qualitative, in-depth key informant interviews with public health experts in municipalities in Bahia. Data were sampled for Bahia’s Salvador microregion, a population of approximately 14 million. Gastroenteritis hospitalization rates among children aged less than five years were evaluated. Declining hospitalization rates were associated with increasing coverage by the PSF (P=0.02). After multivariate adjustment for garbage collection, sanitation, and water supply, evidence of this association was no longer significant (P=0.28). Qualitative analysis confirmed these findings with a framework of health determinants, proximal causes, and health system effects. The PSF, with other public health efforts, was associated with decreasing gastroenteritis hospitalizations in children. Incentives for providers and more patient-centered health delivery may contribute to strengthening the PSF’s role in improving primary health care outcomes in Brazil. PMID:23932060

Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder During Adolescence in the Primary Care Setting: A Concise Review.

PubMed

Brahmbhatt, Khyati; Hilty, Donald M; Hah, Mina; Han, Jaesu; Angkustsiri, Kathy; Schweitzer, Julie B

2016-08-01

Attention deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder with a worldwide prevalence of about 5% in school-age children. This review is intended to assist primary care providers (PCPs) in diagnosing and treating ADHD in adolescents. PubMed, PsychInfo, and Science Citation Index databases were searched from March 1990 to 2015 with the keywords: ADHD, primary care/pediatrics, and children/adolescents. Abstracts addressing diagnosis and/or treatment with 105 citations were identified including supplementary treatment guidelines/books. Adolescent ADHD presents with significant disturbances in attention, academic performance, and family relationships with unique issues associated with this developmental period. Diagnostic challenges include the variable symptom presentation during adolescence, complex differential diagnosis, and limited training and time for PCPs to conduct thorough evaluations. The evidence base for treatments in adolescence in comparison to those in children or adults with ADHD is relatively weak. Providers should be cognizant of prevention, early identification, and treatment of conditions associated with ADHD that emerge during adolescence such as substance use disorders. Adolescent ADHD management for the PCP is complex, requires further research, and perhaps new primary care psychiatric models, to assist in determining the optimal care for patients at this critical period. Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
Clinical outcomes of HIV care delivery models in the US: a systematic review.

PubMed

Kimmel, April D; Martin, Erika G; Galadima, Hadiza; Bono, Rose S; Tehrani, Ali Bonakdar; Cyrus, John W; Henderson, Margaret; Freedberg, Kenneth A; Krist, Alexander H

2016-10-01

With over 1 million people living with HIV, the US faces national challenges in HIV care delivery due to an inadequate HIV specialist workforce and the increasing role of non-communicable chronic diseases in driving morbidity and mortality in HIV-infected patients. Alternative HIV care delivery models, which include substantial roles for advanced practitioners and/or coordination between specialty and primary care settings in managing HIV-infected patients, may address these needs. We aimed to systematically review the evidence on patient-level HIV-specific and primary care health outcomes for HIV-infected adults receiving outpatient care across HIV care delivery models. We identified randomized trials and observational studies from bibliographic and other databases through March 2016. Eligible studies met pre-specified eligibility criteria including on care delivery models and patient-level health outcomes. We considered all available evidence, including non-experimental studies, and evaluated studies for risk of bias. We identified 3605 studies, of which 13 met eligibility criteria. Of the 13 eligible studies, the majority evaluated specialty-based care (9 studies). Across all studies and care delivery models, eligible studies primarily reported mortality and antiretroviral use, with specialty-based care associated with mortality reductions at the clinician and practice levels and with increased antiretroviral initiation or use at the clinician level but not the practice level. Limited and heterogeneous outcomes were reported for other patient-level HIV-specific outcomes (e.g., viral suppression) as well as for primary care health outcomes across all care delivery models. No studies addressed chronic care outcomes related to aging. Limited evidence was available across geographic settings and key populations. As re-design of care delivery in the US continues to evolve, better understanding of patient-level HIV-related and primary care health outcomes, especially across different staffing models and among different patient populations and geographic locations, is urgently needed to improve HIV disease management.
Technical efficiency of women's health prevention programs in Bucaramanga, Colombia: a four-stage analysis.

PubMed

Ruiz-Rodriguez, Myriam; Rodriguez-Villamizar, Laura A; Heredia-Pi, Ileana

2016-10-13

Primary Health Care (PHC) is an efficient strategy to improve health outcomes in populations. Nevertheless, studies of technical efficiency in health care have focused on hospitals, with very little on primary health care centers. The objective of the present study was to use the Data Envelopment Analysis to estimate the technical efficiency of three women's health promotion and disease prevention programs offered by primary care centers in Bucaramanga, Colombia. Efficiency was measured using a four-stage data envelopment analysis with a series of Tobit regressions to account for the effect of quality outcomes and context variables. Input/output information was collected from the institutions' records, chart reviews and personal interviews. Information about contextual variables was obtained from databases from the primary health program in the municipality. A jackknife analysis was used to assess the robustness of the results. The analysis was based on data from 21 public primary health care centers. The average efficiency scores, after adjusting for quality and context, were 92.4 %, 97.5 % and 86.2 % for the antenatal care (ANC), early detection of cervical cancer (EDCC) and family planning (FP) programs, respectively. On each program, 12 of the 21 (57.1 %) health centers were found to be technically efficient; having had the best-practice frontiers. Adjusting for context variables changed the scores and reference rankings of the three programs offered by the health centers. The performance of the women's health prevention programs offered by the centers was found to be heterogeneous. Adjusting for context and health care quality variables had a significant effect on the technical efficiency scores and ranking. The results can serve as a guide to strengthen management and organizational and planning processes related to local primary care services operating within a market-based model such as the one in Colombia.
Primary care of female adolescents with type 1 diabetes mellitus and disordered eating.

PubMed

McCarvill, Rachael; Weaver, Kathryn

2014-09-01

To identify the role of the nurse practitioner in caring for female adolescents with type 1 diabetes mellitus at risk for disordered eating behaviour and to formulate clinical recommendations for nurse practitioners in the primary care setting. Transition into adulthood can be difficult for female adolescents with type 1 diabetes mellitus. Challenges associated with management of this illness may place adolescent females at an increased risk for disordered eating. Discussion paper. Sourced literature from 1991-2013, located through CINAHL, Health Source, Proquest, PubMed, PsychInfo, Web of Science and Medline databases. Nurses involved in the primary care of female adolescents with type 1 diabetes mellitus need to be aware of the increased risk for disordered eating behaviours and develop the competencies to care for both the adolescent and her family to reduce the serious consequences of these behaviours. Awareness and acquisition of the skills required to intervene will enable nurse practitioners to recognize clients at risk for disordered eating, gain appreciation of the motivation of female adolescents with type 1 diabetes mellitus towards disordered eating behaviours and give optimal opportunity for education, counselling and recovery. Future direction for research includes exploration of the experiences of adolescents with type 1 diabetes mellitus; early interventions in the primary care setting; effective educational, preventative or supportive services for adolescents with this illness and their families; and outcomes to emerging technologies for insulin therapy on disordered eating occurrence. © 2014 John Wiley & Sons Ltd.
Evaluation of primary care midwifery in the Netherlands: design and rationale of a dynamic cohort study (DELIVER)

PubMed Central

2012-01-01

Background In the Netherlands, midwives are autonomous medical practitioners and 78% of pregnant women start their maternity care with a primary care midwife. Scientific research to support evidence-based practice in primary care midwifery in the Netherlands has been sparse. This paper describes the research design and methodology of the multicenter multidisciplinary prospective DELIVER study which is the first large-scale study evaluating the quality and provision of primary midwifery care. Methods/Design Between September 2009 and April 2011, data were collected from clients and their partners, midwives and other healthcare professionals across the Netherlands. Clients from twenty midwifery practices received up to three questionnaires to assess the expectations and experiences of clients (e.g. quality of care, prenatal screening, emotions, health, and lifestyle). These client data were linked to data from the Netherlands Perinatal Register and electronic client records kept by midwives. Midwives and practice assistants from the twenty participating practices recorded work-related activities in a diary for one week, to assess workload. Besides, the midwives were asked to complete a questionnaire, to gain insight into collaboration of midwives with other care providers, their tasks and attitude towards their job, and the quality of the care they provide. Another questionnaire was sent to all Dutch midwifery practices which reveals information regarding the organisation of midwifery practices, provision of preconception care, collaboration with other care providers, and provision of care to ethnic minorities. Data at client, midwife and practice level can be linked. Additionally, partners of pregnant women and other care providers were asked about their expectations and experiences regarding the care delivered by midwives and in six practices client consults were videotaped to objectively assess daily practice. Discussion In total, 7685 clients completed at least one questionnaire, 136 midwives and assistants completed a diary with work-related activities (response 100%), 99 midwives completed a questionnaire (92%), and 319 practices across the country completed a questionnaire (61%), 30 partners of clients participated in focus groups, 21 other care providers were interviewed and 305 consults at six midwifery practices were videotaped. The multicenter DELIVER study provides an extensive database with national representative data on the quality of primary care midwifery in the Netherlands. This study will support evidence-based practice in primary care midwifery in the Netherlands and contribute to a better understanding of the maternity care system. PMID:22433820
[The Brazilian Hospital Information System and the acute myocardial infarction hospital care].

PubMed

Escosteguy, Claudia Caminha; Portela, Margareth Crisóstomo; Medronho, Roberto de Andrade; de Vasconcellos, Maurício Teixeira Leite

2002-08-01

To analyze the applicability of the Brazilian Unified Health System's national hospital database to evaluate the quality of acute myocardial infarction hospital care. It was evaluated 1,936 hospital admission forms having acute myocardial infarction (AMI) as primary diagnosis in the municipal district of Rio de Janeiro, Brazil, in 1997. Data was collected from the national hospital database. A stratified random sampling of 391 medical records was also evaluated. AMI diagnosis agreement followed the literature criteria. Variable accuracy analysis was performed using kappa index agreement. The quality of AMI diagnosis registered in hospital admission forms was satisfactory according to the gold standard of the literature. In general, the accuracy of the variables demographics (sex, age group), process (medical procedures and interventions), and outcome (hospital death) was satisfactory. The accuracy of demographics and outcome variables was higher than the one of process variables. Under registration of secondary diagnosis was high in the forms and it was the main limiting factor. Given the study findings and the widespread availability of the national hospital database, it is pertinent its use as an instrument in the evaluation of the quality of AMI medical care.
An algorithm for identification and classification of individuals with type 1 and type 2 diabetes mellitus in a large primary care database

PubMed Central

Sharma, Manuj; Petersen, Irene; Nazareth, Irwin; Coton, Sonia J

2016-01-01

Background Research into diabetes mellitus (DM) often requires a reproducible method for identifying and distinguishing individuals with type 1 DM (T1DM) and type 2 DM (T2DM). Objectives To develop a method to identify individuals with T1DM and T2DM using UK primary care electronic health records. Methods Using data from The Health Improvement Network primary care database, we developed a two-step algorithm. The first algorithm step identified individuals with potential T1DM or T2DM based on diagnostic records, treatment, and clinical test results. We excluded individuals with records for rarer DM subtypes only. For individuals to be considered diabetic, they needed to have at least two records indicative of DM; one of which was required to be a diagnostic record. We then classified individuals with T1DM and T2DM using the second algorithm step. A combination of diagnostic codes, medication prescribed, age at diagnosis, and whether the case was incident or prevalent were used in this process. We internally validated this classification algorithm through comparison against an independent clinical examination of The Health Improvement Network electronic health records for a random sample of 500 DM individuals. Results Out of 9,161,866 individuals aged 0–99 years from 2000 to 2014, we classified 37,693 individuals with T1DM and 418,433 with T2DM, while 1,792 individuals remained unclassified. A small proportion were classified with some uncertainty (1,155 [3.1%] of all individuals with T1DM and 6,139 [1.5%] with T2DM) due to unclear health records. During validation, manual assignment of DM type based on clinical assessment of the entire electronic record and algorithmic assignment led to equivalent classification in all instances. Conclusion The majority of individuals with T1DM and T2DM can be readily identified from UK primary care electronic health records. Our approach can be adapted for use in other health care settings. PMID:27785102
An algorithm for identification and classification of individuals with type 1 and type 2 diabetes mellitus in a large primary care database.

PubMed

Sharma, Manuj; Petersen, Irene; Nazareth, Irwin; Coton, Sonia J

2016-01-01

Research into diabetes mellitus (DM) often requires a reproducible method for identifying and distinguishing individuals with type 1 DM (T1DM) and type 2 DM (T2DM). To develop a method to identify individuals with T1DM and T2DM using UK primary care electronic health records. Using data from The Health Improvement Network primary care database, we developed a two-step algorithm. The first algorithm step identified individuals with potential T1DM or T2DM based on diagnostic records, treatment, and clinical test results. We excluded individuals with records for rarer DM subtypes only. For individuals to be considered diabetic, they needed to have at least two records indicative of DM; one of which was required to be a diagnostic record. We then classified individuals with T1DM and T2DM using the second algorithm step. A combination of diagnostic codes, medication prescribed, age at diagnosis, and whether the case was incident or prevalent were used in this process. We internally validated this classification algorithm through comparison against an independent clinical examination of The Health Improvement Network electronic health records for a random sample of 500 DM individuals. Out of 9,161,866 individuals aged 0-99 years from 2000 to 2014, we classified 37,693 individuals with T1DM and 418,433 with T2DM, while 1,792 individuals remained unclassified. A small proportion were classified with some uncertainty (1,155 [3.1%] of all individuals with T1DM and 6,139 [1.5%] with T2DM) due to unclear health records. During validation, manual assignment of DM type based on clinical assessment of the entire electronic record and algorithmic assignment led to equivalent classification in all instances. The majority of individuals with T1DM and T2DM can be readily identified from UK primary care electronic health records. Our approach can be adapted for use in other health care settings.
Financial implications of the continuity of primary care.

PubMed

Hollander, Marcus J; Kadlec, Helena

2015-01-01

The objective of this study was to assess the financial implications of the continuity of care, for patients with high care needs, by examining the cost of government-funded health care services in British Columbia, Canada. Using British Columbia Ministry of Health administrative databases for fiscal year 2010-2011 and generalized linear models, we estimated cost ratios for 10 cost-related predictor variables, including patients' attachment to the practice. Patients were selected and divided into groups on the basis of their Resource Utilization Band (RUB) and placement in provincial registries for 8 chronic conditions (1,619,941 patients). The final dataset included all high- and very-high-care-needs patients in British Columbia (ie, RUB categories 4 and 5) in 1 or more of the 8 registries who met the screening criteria (222,779 patients). Of the 10 predictors, across 8 medical conditions and both RUBs, patients' attachment to the practice had the strongest relationship to costs (correlations = -0.168 to -0.322). Higher attachment was associated with lower costs. Extrapolation of the findings indicated that an increase of 5% in the overall attachment level, for the selected high-care-needs patients, could have resulted in an estimated cost avoidance of $142 million Canadian for fiscal year 2010-2011. Continuity of care, defined as a patient's attachment to his/her primary care practice, can reduce health care costs over time and across chronic conditions. Health care policy makers may wish to consider creating opportunities for primary care physicians to increase the attachment that their high-care-needs patients have to their practices.
Quality indicators for the detection and management of chronic kidney disease in primary care in Canada derived from a modified Delphi panel approach.

PubMed

Tu, Karen; Bevan, Lindsay; Hunter, Katie; Rogers, Jess; Young, Jacqueline; Nesrallah, Gihad

2017-01-01

The detection and management of chronic kidney disease lies within primary care; however, performance measures applicable in the Canadian context are lacking. We sought to develop a set of primary care quality indicators for chronic kidney disease in the Canadian setting and to assess the current state of the disease's detection and management in primary care. We used a modified Delphi panel approach, involving 20 panel members from across Canada (10 family physicians, 7 nephrologists, 1 patient, 1 primary care nurse and 1 pharmacist). Indicators identified from peer-reviewed and grey literature sources were subjected to 3 rounds of voting to develop a set of quality indicators for the detection and management of chronic kidney disease in the primary care setting. The final indicators were applied to primary care electronic medical records in the Electronic Medical Record Administrative data Linked Database (EMRALD) to assess the current state of primary care detection and management of chronic kidney disease in Ontario. Seventeen indicators made up the final list, with 1 under the category Prevalence, Incidence and Mortality; 4 under Screening, Diagnosis and Risk Factors; 11 under Management; and 1 under Referral to a Specialist. In a sample of 139 993 adult patients not on dialysis, 6848 (4.9%) had stage 3 or higher chronic kidney disease, with the average age of patients being 76.1 years (standard deviation [SD] 11.0); 62.9% of patients were female. Diagnosis and screening for chronic kidney disease were poorly performed. Only 27.1% of patients with stage 3 or higher disease had their diagnosis documented in their cumulative patient profile. Albumin-creatinine ratio testing was only performed for 16.3% of patients with a low estimated glomerular filtration rate (eGFR) and for 28.5% of patients with risk factors for chronic kidney disease. Family physicians performed relatively better with the management of chronic kidney disease, with 90.4% of patients with stage 3 or higher disease having an eGFR performed in the previous 18 months and 83.1% having a blood pressure recorded in the previous 9 months. We propose a set of measurable indicators to evaluate the quality of the management of chronic kidney disease in primary care. These indicators may be used to identify opportunities to improve current practice in Canada.
Why do patients with cancer access out-of-hours primary care? A retrospective study.

PubMed

Adam, Rosalind; Wassell, Patrick; Murchie, Peter

2014-02-01

Identifying why patients with cancer seek out-of-hours (OOH) primary medical care could highlight potential gaps in anticipatory cancer care. To explore the reasons for contact and the range and prevalence of presenting symptoms in patients with established cancer who presented to a primary care OOH department. A retrospective review of 950 anonymous case records for patients with cancer who contacted the OOH general practice service in Grampian, Scotland between 1 January 2010 and 31 December 2011. Subjects were identified by filtering the OOH computer database using the Read Codes 'neoplasm', 'terminal care', and 'terminal illness'. Consultations by patients without cancer and repeated consultations by the same patient were excluded. Data were anonymised. Case records were read independently by two authors who determined the presenting symptom(s). Anonymous case records were reviewed for 950 individuals. Eight hundred and fifty-two patients made contact because of a symptom. The remaining 97 were mostly administrative and data were missing for one patient. The most frequent symptoms were pain (n = 262/852, 30.8%); nausea/vomiting (n = 102/852, 12.0%); agitation (n = 53/852, 6.2%); breathlessness (n = 51/852, 6.0%); and fatigue (n = 48/852, 5.6%). Of the 262 patients who presented with pain, at least 127 (48.5%) had metastatic disease and 141 (53.8%) were already prescribed strong opiate medication. Almost one-third of patients with cancer seeking OOH primary medical care did so because of poorly controlled pain. Pain management should specifically be addressed during routine anticipatory care planning.
Effects of implementing electronic medical records on primary care billings and payments: a before–after study

PubMed Central

Shultz, Susan E.; Tu, Karen

2013-01-01

Background Several barriers to the adoption of electronic medical records (EMRs) by family physicians have been discussed, including the costs of implementation, impact on work flow and loss of productivity. We examined billings and payments received before and after implementation of EMRs among primary care physicians in the province of Ontario. We also examined billings and payments before and after switching from a fee-for-service to a capitation payment model, because EMR implementation coincided with primary care reform in the province. Methods We used information from the Electronic Medical Record Administrative Data Linked Database (EMRALD) to conduct a retrospective before–after study. The EMRALD database includes EMR data extracted from 183 community-based family physicians in Ontario. We included EMRALD physicians who were eligible to bill the Ontario Health Insurance Plan at least 18 months before and after the date they started using EMRs and had completed a full 18-month period before Mar. 31, 2011, when the study stopped. The main outcome measures were physicians’ monthly billings and payments for office visits and total annual payments received from all government sources. Two index dates were examined: the date physicians started using EMRs and were in a stable payment model (n = 64) and the date physicians switched from a fee-for-service to a capitation payment model (n = 42). Results Monthly billings and payments for office visits did not decrease after the implementation of EMRs. The overall weighted mean annual payment from all government sources increased by 27.7% after the start of EMRs among EMRALD physicians; an increase was also observed among all other primary care physicians in Ontario, but it was not as great (14.4%). There was a decline in monthly billings and payments for office visits after physicians changed payment models, but an increase in their overall annual government payments. Interpretation Implementation of EMRs by primary care physicians did not result in decreased billings or government payments for office visits. Further economic analyses are needed to measure the effects of EMR implementation on productivity and the costs of implementing an EMR system, including the costs of nonclinical work by physicians and their staff. PMID:25077111
Addressing the crisis of GP recruitment and retention: a systematic review.

PubMed

Marchand, Catherine; Peckham, Stephen

2017-04-01

The numbers of GPs and training places in general practice are declining, and retaining GPs in their practices is an increasing problem. To identify evidence on different approaches to retention and recruitment of GPs, such as intrinsic versus extrinsic motivational determinants. Synthesis of qualitative and quantitative research using seven electronic databases from 1990 onwards (Medline, Embase, Cochrane Library, Health Management Information Consortium [HMIC], Cumulative Index to Nursing and Allied Health Literature (Cinahl), PsycINFO, and the Turning Research Into Practice [TRIP] database). A qualitative approach to reviewing the literature on recruitment and retention of GPs was used. The studies included were English-language studies from Organisation for Economic Cooperation and Development countries. The titles and abstracts of 138 articles were reviewed and analysed by the research team. Some of the most important determinants to increase recruitment in primary care were early exposure to primary care practice, the fit between skills and attributes, and a significant experience in a primary care setting. Factors that seemed to influence retention were subspecialisation and portfolio careers, and job satisfaction. The most important determinants of recruitment and retention were intrinsic and idiosyncratic factors, such as recognition, rather than extrinsic factors, such as income. Although the published evidence relating to GP recruitment and retention is limited, and most focused on attracting GPs to rural areas, the authors found that there are clear overlaps between strategies to increase recruitment and retention. Indeed, the most influential factors are idiosyncratic and intrinsic to the individuals. © British Journal of General Practice 2017.
Addressing the crisis of GP recruitment and retention: a systematic review

PubMed Central

Marchand, Catherine; Peckham, Stephen

2017-01-01

Background The numbers of GPs and training places in general practice are declining, and retaining GPs in their practices is an increasing problem. Aim To identify evidence on different approaches to retention and recruitment of GPs, such as intrinsic versus extrinsic motivational determinants. Design and setting Synthesis of qualitative and quantitative research using seven electronic databases from 1990 onwards (Medline, Embase, Cochrane Library, Health Management Information Consortium [HMIC], Cumulative Index to Nursing and Allied Health Literature (Cinahl), PsycINFO, and the Turning Research Into Practice [TRIP] database). Method A qualitative approach to reviewing the literature on recruitment and retention of GPs was used. The studies included were English-language studies from Organisation for Economic Cooperation and Development countries. The titles and abstracts of 138 articles were reviewed and analysed by the research team. Results Some of the most important determinants to increase recruitment in primary care were early exposure to primary care practice, the fit between skills and attributes, and a significant experience in a primary care setting. Factors that seemed to influence retention were subspecialisation and portfolio careers, and job satisfaction. The most important determinants of recruitment and retention were intrinsic and idiosyncratic factors, such as recognition, rather than extrinsic factors, such as income. Conclusion Although the published evidence relating to GP recruitment and retention is limited, and most focused on attracting GPs to rural areas, the authors found that there are clear overlaps between strategies to increase recruitment and retention. Indeed, the most influential factors are idiosyncratic and intrinsic to the individuals. PMID:28289014
Cytology in the diagnosis of cervical cancer in symptomatic young women: a retrospective review.

PubMed

Lim, Anita Ww; Landy, Rebecca; Castanon, Alejandra; Hollingworth, Antony; Hamilton, Willie; Dudding, Nick; Sasieni, Peter

2016-12-01

Cervical cancer in young women presents a diagnostic challenge because gynaecological symptoms are common but underlying disease is rare. To explore the potential for using cytology as a diagnostic aid for cervical cancer in young women. Retrospective review of primary care records and cytology data from the national cervical screening database and national audit of cervical cancers. Four datasets of women aged 20-29 years in England were examined: primary care records and national screening data from an in-depth study of cervical cancers; cytology from the national audit of cervical cancers; whole-population cytology from the national screening database; and general-population primary care records from the Clinical Practice Research Datalink. The authors explored the sensitivity and positive predictive value (PPV) of symptomatic cytology (earliest <12 months before diagnosis) to cervical cancer. The estimated prevalence of cervical cancer among symptomatic women was between 0.4% and 0.9%. The sensitivity of moderate dyskaryosis (high-grade squamous intraepithelial lesion [HSIL]) or worse in women aged 20-29 years was 90.9% to 96.2% across datasets, regardless of symptom status. The PPV was estimated to be between 10.0% and 30.0%. For women aged 20-24 years, the PPV of '?invasive squamous carcinoma' was 25.4%, and 2.0% for severe or worse cytology. Cytology has value beyond screening, and could be used as a diagnostic aid for earlier detection of cervical cancer in young women with gynaecological symptoms by ruling in urgent referral. © British Journal of General Practice 2016.
Cytology in the diagnosis of cervical cancer in symptomatic young women: a retrospective review

PubMed Central

Lim, Anita WW; Landy, Rebecca; Castanon, Alejandra; Hollingworth, Antony; Hamilton, Willie; Dudding, Nick; Sasieni, Peter

2016-01-01

Background Cervical cancer in young women presents a diagnostic challenge because gynaecological symptoms are common but underlying disease is rare. Aim To explore the potential for using cytology as a diagnostic aid for cervical cancer in young women. Design and setting Retrospective review of primary care records and cytology data from the national cervical screening database and national audit of cervical cancers. Method Four datasets of women aged 20–29 years in England were examined: primary care records and national screening data from an in-depth study of cervical cancers; cytology from the national audit of cervical cancers; whole-population cytology from the national screening database; and general-population primary care records from the Clinical Practice Research Datalink. The authors explored the sensitivity and positive predictive value (PPV) of symptomatic cytology (earliest <12 months before diagnosis) to cervical cancer. Results The estimated prevalence of cervical cancer among symptomatic women was between 0.4% and 0.9%. The sensitivity of moderate dyskaryosis (high-grade squamous intraepithelial lesion [HSIL]) or worse in women aged 20–29 years was 90.9% to 96.2% across datasets, regardless of symptom status. The PPV was estimated to be between 10.0% and 30.0%. For women aged 20–24 years, the PPV of ‘?invasive squamous carcinoma’ was 25.4%, and 2.0% for severe or worse cytology. Conclusion Cytology has value beyond screening, and could be used as a diagnostic aid for earlier detection of cervical cancer in young women with gynaecological symptoms by ruling in urgent referral. PMID:27777232
The contribution of Physician Assistants in primary care: a systematic review

PubMed Central

2013-01-01

Background Primary care provision is important in the delivery of health care but many countries face primary care workforce challenges. Increasing demand, enlarged workloads, and current and anticipated physician shortages in many countries have led to the introduction of mid-level professionals, such as Physician Assistants (PAs). Objective: This systematic review aimed to appraise the evidence of the contribution of PAs within primary care, defined for this study as general practice, relevant to the UK or similar systems. Methods Medline, CINAHL, PsycINFO, BNI, SSCI and SCOPUS databases were searched from 1950 to 2010. Eligibility criteria: PAs with a recognised PA qualification, general practice/family medicine included and the findings relevant to it presented separately and an English language journal publication. Two reviewers independently identified relevant publications, assessed quality using Critical Appraisal Skills Programme tools and extracted findings. Findings were classified and synthesised narratively as factors related to structure, process or outcome of care. Results 2167 publications were identified, of which 49 met our inclusion criteria, with 46 from the United States of America (USA). Structure: approximately half of PAs are reported to work in primary care in the USA with good support and a willingness to employ amongst doctors. Process: the majority of PAs’ workload is the management of patients with acute presentations. PAs tend to see younger patients and a different caseload to doctors, and require supervision. Studies of costs provide mixed results. Outcomes: acceptability to patients and potential patients is consistently found to be high, and studies of appropriateness report positively. Overall the evidence was appraised as of weak to moderate quality, with little comparative data presented and little change in research questions over time. Limitations: identification of a broad range of studies examining ‘contribution’ made meta analysis or meta synthesis untenable. Conclusions The research evidence of the contribution of PAs to primary care was mixed and limited. However, the continued growth in employment of PAs in American primary care suggests that this professional group is judged to be of value by increasing numbers of employers. Further specific studies are needed to fill in the gaps in our knowledge about the effectiveness of PAs’ contribution to the international primary care workforce. PMID:23773235
Kabuki syndrome: a challenge for the primary care provider.

PubMed

Crane, Bonnie; Alpert, Patricia T; Cyrkiel, Dianne; Jauregui, Alan

2013-10-01

Using a case format, the pathogenesis, clinical manifestations, diagnosis, and management of Kabuki syndrome, a rare genetic condition, is presented. Nurse practitioners (NPs) may encounter patients presenting to the primary care setting with this rare syndrome; understanding this condition may help them to better care for these patients. A case presentation of a pediatric patient supported by the currently available literature from multiple health and medial databases. Kabuki syndrome is a rare phenomenon that occurs in 1 in every 32,000 births. A diagnosis of this syndrome may take several months to years because there are no specific tests, and the physical features may be subtle at birth, becoming more pronounced over a period of time during childhood. The degree of disease severity varies widely. Understanding this syndrome increases the NP's ability to provide primary care to affected patients and their families. Management of this condition requires the NP take on the role of gatekeeper, so timely coordination of specialty or subspecialty services is provided. Special consideration should be given to monitoring caregiver fatigue and impact on siblings so family members can be directed to the appropriate support services. ©2013 The Author(s) ©2013 American Association of Nurse Practitioners.
Organizational climate in primary care settings: implications for nurse practitioner practice.

PubMed

Poghosyan, Lusine; Nannini, Angela; Clarke, Sean

2013-03-01

The purpose of this review is to investigate literature related to organizational climate, define organizational climate, and identify its domains for nurse practitioner (NP) practice in primary care settings. A search was conducted using MEDLINE, PubMed, HealthSTAR/Ovid, ISI Web of Science, and several other health policy and nursingy databases. In primary care settings, organizational climate for NPs is a set of organizational attributes, which are perceived by NPs about their practice setting, emerge from the way the organization interacts with NPs, and affect NP behaviors and outcomes. Autonomy, NP-physician relations, and professional visibility were identified as organizational climate domains. NPs should be encouraged to assess organizational climate in their workplace and choose organizations that promote autonomy, collegiality between NPs and physicians, and encourage professional visibility. Organizational and NP awareness of qualities that foster NP practice will be a first step for developing strategies to creating an optimal organizational climate for NPs to deliver high-quality care. More research is needed to develop a comprehensive conceptual framework for organizational climate and develop new instruments to accurately measure organizational climate and link it to NP and patient outcomes. ©2012 The Author(s) Journal compilation ©2012 American Association of Nurse Practitioners.
Evaluation of diabetes care management in primary clinics based on the guidelines of American Diabetes Association.

PubMed

Albarrak, Ahmed Ismail; Mohammed, Rafiuddin; Assery, Bushra; Allam, Dalya; Morit, Sarah Al; Saleh, Reem Al; Zare'a, Reem

2018-01-01

There is a rapid increase in the incidence of diabetes mellitus in Saudi Arabia. Diabetes management is an essential constituent to prevent prognosis of diabetes complications. The main objective of this study was to assess diabetes care in primary clinics based on the guidelines of American Diabetes Association (ADA). A retrospective study at King Khaled University Hospitals, Riyadh, Saudi Arabia. A total of 200 patients were randomly selected from the databases of primary care clinics. An evaluation checklist was created based on the ADA treatment guidelines such as medical history, physical examination, laboratory evaluation, and referrals. The result showed that elements achieving the ADA targets for overall care were medical history (44.9%), physical examination (59.6%), laboratory evaluation (36.3%), and referrals (19.3%). The other subelement indicators such as referral to diabetes self-management education clinics (10%), dental examination (2%), HbA1c regular monitoring (33.5%), and blood pressure determination (100%) were documented with adherence to ADA standards. Diabetes management standards are an essential element in the success of the management plan. Most of the elements examined are not in full compliance with the ADA standard. Continues monitoring and self-review are recommended.

Nursing practices in the primary health care context: a scoping review 1

PubMed Central

Barbiani, Rosangela; Nora, Carlise Rigon Dalla; Schaefer, Rafaela

2016-01-01

ABSTRACT Objective: to identify and categorize the practices performed by nurses working in Primary Health Care and Family Health Strategy Units in light of responsibilities established by the profession's legal and programmatic frameworks and by the Brazilian Unified Health System. Method: a scoping review was conducted in the following databases: LILACS, IBECS, BDENF, CINAHL and MEDLINE, and the Cochrane and SciELO libraries. Original research papers written by nurses addressing nursing practices in the primary health care context were included. Results: the review comprised 30 studies published between 2005 and 2014. Three categories emerged from the analysis: practices in the service; practices in the community; and management and education practices. Conclusion: the challenges faced by nurses are complex, as care should be centered on the population's health needs, which requires actions at other levels of clinical and health responsibility. Brazilian nursing has achieved important advancements since the implementation of policies intended to reorganize work. There is, however, a need to shift work processes from being focused on individual procedures to being focused on patients so that an enlarged clinic is the ethical-political imperative guiding the organization of services and professional intervention. PMID:27579928
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.
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
The epidemiology of malpractice claims in primary care: a systematic review

PubMed Central

Wallace, E; Lowry, J; Smith, S M; Fahey, T

2013-01-01

Objectives The aim of this systematic review was to examine the epidemiology of malpractice claims in primary care. Design A computerised systematic literature search was conducted. Studies were included if they reported original data (≥10 cases) pertinent to malpractice claims, were based in primary care and were published in the English language. Data were synthesised using a narrative approach. Setting Primary care. Participants Malpractice claimants. Primary outcome Malpractice claim (defined as a written demand for compensation for medical injury). We recorded: medical misadventure cited in claims, missed/delayed diagnoses cited in claims, outcome of claims, prevalence of claims and compensation awarded to claimants. Results Of the 7152 articles retrieved by electronic search, a total of 34 studies met the inclusion criteria and were included in the narrative analysis. Twenty-eight studies presented data from medical indemnity malpractice claims databases and six studies presented survey data. Fifteen studies were based in the USA, nine in the UK, seven in Australia, one in Canada and two in France. The commonest medical misadventure resulting in claims was failure to or delay in diagnosis, which represented 26–63% of all claims across included studies. Common missed or delayed diagnoses included cancer and myocardial infarction in adults and meningitis in children. Medication error represented the second commonest domain representing 5.6–20% of all claims across included studies. The prevalence of malpractice claims in primary care varied across countries. In the USA and Australia when compared with other clinical disciplines, general practice ranked in the top five specialties accounting for the most claims, representing 7.6–20% of all claims. However, the majority of claims were successfully defended. Conclusions This review of malpractice claims in primary care highlights diagnosis and medication error as areas to be prioritised in developing educational strategies and risk management systems. PMID:23869100
Roadmap for the development of the University of North Carolina at Chapel Hill Genitourinary OncoLogy Database--UNC GOLD.

PubMed

Gallagher, Sarah A; Smith, Angela B; Matthews, Jonathan E; Potter, Clarence W; Woods, Michael E; Raynor, Mathew; Wallen, Eric M; Rathmell, W Kimryn; Whang, Young E; Kim, William Y; Godley, Paul A; Chen, Ronald C; Wang, Andrew; You, Chaochen; Barocas, Daniel A; Pruthi, Raj S; Nielsen, Matthew E; Milowsky, Matthew I

2014-01-01

The management of genitourinary malignancies requires a multidisciplinary care team composed of urologists, medical oncologists, and radiation oncologists. A genitourinary (GU) oncology clinical database is an invaluable resource for patient care and research. Although electronic medical records provide a single web-based record used for clinical care, billing, and scheduling, information is typically stored in a discipline-specific manner and data extraction is often not applicable to a research setting. A GU oncology database may be used for the development of multidisciplinary treatment plans, analysis of disease-specific practice patterns, and identification of patients for research studies. Despite the potential utility, there are many important considerations that must be addressed when developing and implementing a discipline-specific database. The creation of the GU oncology database including prostate, bladder, and kidney cancers with the identification of necessary variables was facilitated by meetings of stakeholders in medical oncology, urology, and radiation oncology at the University of North Carolina (UNC) at Chapel Hill with a template data dictionary provided by the Department of Urologic Surgery at Vanderbilt University Medical Center. Utilizing Research Electronic Data Capture (REDCap, version 4.14.5), the UNC Genitourinary OncoLogy Database (UNC GOLD) was designed and implemented. The process of designing and implementing a discipline-specific clinical database requires many important considerations. The primary consideration is determining the relationship between the database and the Institutional Review Board (IRB) given the potential applications for both clinical and research uses. Several other necessary steps include ensuring information technology security and federal regulation compliance; determination of a core complete dataset; creation of standard operating procedures; standardizing entry of free text fields; use of data exports, queries, and de-identification strategies; inclusion of individual investigators' data; and strategies for prioritizing specific projects and data entry. A discipline-specific database requires a buy-in from all stakeholders, meticulous development, and data entry resources to generate a unique platform for housing information that may be used for clinical care and research with IRB approval. The steps and issues identified in the development of UNC GOLD provide a process map for others interested in developing a GU oncology database. Copyright © 2014 Elsevier Inc. All rights reserved.
Administrative Data Algorithms Can Describe Ambulatory Physician Utilization

PubMed Central

Shah, Baiju R; Hux, Janet E; Laupacis, Andreas; Zinman, Bernard; Cauch-Dudek, Karen; Booth, Gillian L

2007-01-01

Objective To validate algorithms using administrative data that characterize ambulatory physician care for patients with a chronic disease. Data Sources Seven-hundred and eighty-one people with diabetes were recruited mostly from community pharmacies to complete a written questionnaire about their physician utilization in 2002. These data were linked with administrative databases detailing health service utilization. Study Design An administrative data algorithm was defined that identified whether or not patients received specialist care, and it was tested for agreement with self-report. Other algorithms, which assigned each patient to a primary care and specialist physician, were tested for concordance with self-reported regular providers of care. Principal Findings The algorithm to identify whether participants received specialist care had 80.4 percent agreement with questionnaire responses (κ = 0.59). Compared with self-report, administrative data had a sensitivity of 68.9 percent and specificity 88.3 percent for identifying specialist care. The best administrative data algorithm to assign each participant's regular primary care and specialist providers was concordant with self-report in 82.6 and 78.2 percent of cases, respectively. Conclusions Administrative data algorithms can accurately match self-reported ambulatory physician utilization. PMID:17610448
Readiness for the Patient-Centered Medical Home: Structural Capabilities of Massachusetts Primary Care Practices

PubMed Central

Friedberg, Mark W.; Safran, Dana G.; Coltin, Kathryn L.; Dresser, Marguerite

2008-01-01

Background The Patient-Centered Medical Home (PCMH), a popular model for primary care reorganization, includes several structural capabilities intended to enhance quality of care. The extent to which different types of primary care practices have adopted these capabilities has not been previously studied. Objective To measure the prevalence of recommended structural capabilities among primary care practices and to determine whether prevalence varies among practices of different size (number of physicians) and administrative affiliation with networks of practices. Design Cross-sectional analysis. Participants One physician chosen at random from each of 412 primary care practices in Massachusetts was surveyed about practice capabilities during 2007. Practice size and network affiliation were obtained from an existing database. Measurements Presence of 13 structural capabilities representing 4 domains relevant to quality: patient assistance and reminders, culture of quality, enhanced access, and electronic health records (EHRs). Main Results Three hundred eight (75%) physicians responded, representing practices with a median size of 4 physicians (range 2–74). Among these practices, 64% were affiliated with 1 of 9 networks. The prevalence of surveyed capabilities ranged from 24% to 88%. Larger practice size was associated with higher prevalence for 9 of the 13 capabilities spanning all 4 domains (P < 0.05). Network affiliation was associated with higher prevalence of 5 capabilities (P < 0.05) in 3 domains. Associations were not substantively altered by statistical adjustment for other practice characteristics. Conclusions Larger and network-affiliated primary care practices are more likely than smaller, non-affiliated practices to have adopted several recommended capabilities. In order to achieve PCMH designation, smaller non-affiliated practices may require the greatest investments. Electronic supplementary material The online version of this article (doi:10.1007/s11606-008-0856-x) contains supplementary material, which is available to authorized users. PMID:19050977
Social accountability of medical schools and academic primary care training in Latin America: principles but not practice.

PubMed

Puschel, Klaus; Rojas, Paulina; Erazo, Alvaro; Thompson, Beti; Lopez, Jorge; Barros, Jorge

2014-08-01

Latin America has one of the highest rates of health disparities in the world and is experiencing a steep increase in its number of medical schools. It is not clear if medical school authorities consider social responsibility, defined as the institutional commitment to contribute to the improvement of community well-being, as a priority and if there are any organizational strategies that could reduce health disparities. To study the significance and relevance of social responsibility in the academic training of medical schools in Latin America. The study combined a qualitative thematic literature review of three databases with a quantitative design based on a sample of nine Latin American and non-Latin American countries. The thematic analysis showed high agreement among academic groups on considering medical schools as 'moral agents', part of a 'social contract' and with an institutional responsibility to reduce health disparities mainly through the implementation of strong academic primary care programs. The quantitative analysis showed a significant association between higher development of academic primary care programs and lower level of health disparities by country (P = 0.028). However, the data showed that most Latin American medical schools did not prioritize graduate primary care training. The study shows a discrepancy between the importance given to social responsibility and academic primary care training in Latin America and the practices implemented by medical schools. It highlights the need to refocus medical education policies in the region. © The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
Performance characteristics of visualising the cervix in symptomatic young females: a review of primary care records in females with and without cervical cancer.

PubMed

Lim, Anita Wey Wey; Hamilton, Willie; Hollingworth, Antony; Stapley, Sally; Sasieni, Peter

2016-03-01

The current strategy for timely detection of cervical cancer in young females centres on visualising the cervix when females present with gynaecological symptoms, but is based on expert opinion without an evidence base. To assess visualising the cervix in primary care in young females with gynaecological symptoms. A review of primary care records for females in England aged 20-29 years with cervical cancer (nationwide interview-based study) and in the general population (Clinical Practice Research Datalink database). From primary care records the proportion of females was identified with gynaecological symptoms who had documented cervical examination in the year before diagnosis (cancers) and in 1-year age bands (general population). Of these, the proportion was identified that was then referred for suspected malignancy. Only 39% of young females with cervical cancer had documented examination at symptomatic presentation. Visualisation resulted in referral for suspected malignancy for 18% of those examined (95% confidence interval = 5% to 40%). Very few (<1.7%) symptomatic females in the general population had documented cervical examination. None were referred for suspected malignancy at the time. The sensitivity of cervical examination to detect cancer is very low, highlighting the need for better triage tools for primary care. Until such tools are identified GPs should continue to consider cervical cancer when symptoms persist and the cervix is not obviously abnormal on clinical examination. Further research on additional triage tools such as cervical cytology used as a diagnostic aid is needed urgently. © British Journal of General Practice 2016.
Associations of family characteristics with perceptions of care among parents of children with autism.

PubMed

Sobotka, S A; Francis, A; Vander Ploeg Booth, K

2016-01-01

Although autism spectrum disorder (ASD) is an increasingly common chronic disability, primary care provider (PCPs) report deficits in providing primary care for children with ASD, and parents report lapses in receipt of medical home services. In this study, we describe parental experiences with specific medical home components for their children with ASD. We analysed data from all children within the National Survey of Children with Special Health Care Needs database with ASD and a usual place for care (n = 2859). We evaluated the receipt of core medical home components: accessible, comprehensive, coordinated, family centred and compassionate and culturally sensitive care. Children were mean age 10.1 years, and respondents were 75% mothers and 95% reported having a primary care provider (PCP). Seventy-one percent reported care to be usually comprehensive, over three-fourths of respondents reported care to be family centred and compassionate and 87% reported care to be culturally sensitive. Of the parents who reported a need for care coordination (n = 1049), only 14% of parents reported usually getting the help they needed. More educated, English-speaking, non-Hispanic White mothers of older children supported by private insurance were more likely to report never getting as much help coordinating care as desired. Coordination with education services are especially important for children with ASD, yet 27% of parents reported dissatisfaction with PCPs' communication with schools or early intervention. Although parents report a high level of access to PCPs and places for care as well as receiving most core components of the medical home, care coordination activities are lacking for children with ASD. More resourced families are particularly likely to report unmet needs. © 2015 John Wiley & Sons Ltd.
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.
Factors influencing the development of primary care data collection projects from electronic health records: a systematic review of the literature.

PubMed

Gentil, Marie-Line; Cuggia, Marc; Fiquet, Laure; Hagenbourger, Camille; Le Berre, Thomas; Banâtre, Agnès; Renault, Eric; Bouzille, Guillaume; Chapron, Anthony

2017-09-25

Primary care data gathered from Electronic Health Records are of the utmost interest considering the essential role of general practitioners (GPs) as coordinators of patient care. These data represent the synthesis of the patient history and also give a comprehensive picture of the population health status. Nevertheless, discrepancies between countries exist concerning routine data collection projects. Therefore, we wanted to identify elements that influence the development and durability of such projects. A systematic review was conducted using the PubMed database to identify worldwide current primary care data collection projects. The gray literature was also searched via official project websites and their contact person was emailed to obtain information on the project managers. Data were retrieved from the included studies using a standardized form, screening four aspects: projects features, technological infrastructure, GPs' roles, data collection network organization. The literature search allowed identifying 36 routine data collection networks, mostly in English-speaking countries: CPRD and THIN in the United Kingdom, the Veterans Health Administration project in the United States, EMRALD and CPCSSN in Canada. These projects had in common the use of technical facilities that range from extraction tools to comprehensive computing platforms. Moreover, GPs initiated the extraction process and benefited from incentives for their participation. Finally, analysis of the literature data highlighted that governmental services, academic institutions, including departments of general practice, and software companies, are pivotal for the promotion and durability of primary care data collection projects. Solid technical facilities and strong academic and governmental support are required for promoting and supporting long-term and wide-range primary care data collection projects.
A randomized trial of treatments for high-utilizing somatizing patients.

PubMed

Barsky, Arthur J; Ahern, David K; Bauer, Mark R; Nolido, Nyryan; Orav, E John

2013-11-01

Somatization and hypochondriacal health anxiety are common sources of distress, impairment, and costly medical utilization in primary care practice. A range of interventions is needed to improve the care of these patients. To determine the effectiveness of two cognitive behavioral interventions for high-utilizing, somatizing patients, using the resources found in a routine care setting. Patients were randomly assigned to a two-step cognitive behavioral treatment program accompanied by a training seminar for their primary care physicians, or to relaxation training. Providers routinely working in these patients' primary care practices delivered the cognitive behavior therapy and relaxation training. A follow-up assessment was completed immediately prior to treatment and 6 and 12 months later. Eighty-nine medical outpatients with elevated levels of somatization, hypochondriacal health anxiety, and medical care utilization. Somatization and hypochondriasis, overall psychiatric distress, and role impairment were assessed with well-validated, self-report questionnaires. Outpatient visits and medical care costs before and after the intervention were obtained from the encounter claims database. At 6 month and 12 month follow-up, both intervention groups showed significant improvements in somatization (p < 0.01), hypochondriacal symptoms (p < 0.01), overall psychiatric distress (p < 0.01), and role impairment (p < 0.01). Outcomes did not differ significantly between the two groups. When both groups were combined, ambulatory visits declined from 10.3 to 8.8 (p = 0.036), and mean ambulatory costs decreased from $3,574 to $2,991 (pp = 0.028) in the year preceding versus the year following the interventions. Psychiatric visits and costs were unchanged. Two similar cognitive behavioral interventions, delivered with the resources available in routine primary care, improved somatization, hypochondriacal symptoms, overall psychiatric distress, and role function. They also reduced the ambulatory visits and costs of these high utilizing outpatients.
[User embracement in the Family Health Strategy in Brazil: an integrative review].

PubMed

Garuzi, Miriane; Achitti, Maria Cecília de Oliveira; Sato, Cintia Ayame; Rocha, Suelen Alves; Spagnuolo, Regina Stella

2014-02-01

To review the literature regarding the application of the notion of user embracement and to identify the contributions of this concept for primary health care practices in Brazil. We carried out an integrative review of the literature regarding primary health care. The following databases were searched: LILACS, SciELO, and MEDLINE, covering the period from 2006 to 2010. The following search terms were used in LILACS and SciELO: "acolhimento" and "programa saúde da família" and "saúde". For MEDLINE, the terms "user embracement" and "family health program" and "health" were used. The review was performed in November 2010. We identified 21 articles meeting the inclusion criteria, all of which described studies carried out in Brazil. The articles were divided into three empirical categories: integration and embracement; primary care work process; and evaluation of services. These are complementary categories that converge to two main views of embracement: the first sees embracement as a means of reorganizing the primary health care environment, and the second sees embracement as an attitude towards users. The review also shows that embracement may be a management tool that supports the Unified Health System and is associated with the principles of comprehensiveness and universality. Embracement is able to create a bond between health care workers and users. It promotes self-care, a better understanding of disease, as well as user co-responsibility for treatment. In addition, it facilitates universal access, strengthens multiprofessional and intersectoral work, qualifies care, humanizes practices, and encourages actions to combat prejudice. Nevertheless, the perspective of health care users regarding embracement deserves more attention and should be the focus of future studies.
Primary prevention of cardiovascular diseases: a cost study in family practices.

PubMed

de Bekker-Grob, Esther W; van Dulmen, Sandra; van den Berg, Matthijs; Verheij, Robert A; Slobbe, Laurentius C J

2011-07-06

Considering the scarcity of health care resources and the high costs associated with cardiovascular diseases, we investigated the spending on cardiovascular primary preventive activities and the prescribing behaviour of primary preventive cardiovascular medication (PPCM) in Dutch family practices (FPs). A mixed methods design was used, which consisted of a questionnaire (n = 80 FPs), video recordings of hypertension- or cholesterol-related general practitioner visits (n = 56), and the database of Netherlands Information Network of General Practice (n = 45 FPs; n = 157,137 patients). The questionnaire and video recordings were used to determine the average frequency and time spent on cardiovascular primary preventive activities per FP respectively. Taking into account the annual income and full time equivalents of general practitioners, health care assistants, and practice nurses as well as the practice costs, the total spending on cardiovascular primary preventive activities in Dutch FPs was calculated. The database of Netherlands Information Network of General Practice was used to determine the prescribing behaviour in Dutch FPs by conducting multilevel regression models and adjusting for patient and practice characteristics. Total expenditure on cardiovascular primary preventive activities in FPs in 2009 was €38.8 million (€2.35 per capita), of which 47% was spent on blood pressure measurements, 26% on cardiovascular risk profiling, and 11% on lifestyle counselling. Fifteen percent (€11 per capita) of all cardiovascular medication prescribed in FPs was a PPCM. FPs differed greatly on prescription of PPCM (odds ratio of 3.1). Total costs of cardiovascular primary preventive activities in FPs such as blood pressure measurements and lifestyle counselling are relatively low compared to the costs of PPCM. There is considerable heterogeneity in prescribing behaviour of PPCM between FPs. Further research is needed to determine whether such large differences in prescription rates are justified. Striving for an optimal use of cardiovascular primary preventive activities might lead to similar health outcomes, but may achieve important cost savings.
Democratic and Republican physicians provide different care on politicized health issues.

PubMed

Hersh, Eitan D; Goldenberg, Matthew N

2016-10-18

Physicians frequently interact with patients about politically salient health issues, such as drug use, firearm safety, and sexual behavior. We investigate whether physicians' own political views affect their treatment decisions on these issues. We linked the records of over 20,000 primary care physicians in 29 US states to a voter registration database, obtaining the physicians' political party affiliations. We then surveyed a sample of Democratic and Republican primary care physicians. Respondents evaluated nine patient vignettes, three of which addressed especially politicized health issues (marijuana, abortion, and firearm storage). Physicians rated the seriousness of the issue presented in each vignette and their likelihood of engaging in specific management options. On the politicized health issues-and only on such issues-Democratic and Republican physicians differed substantially in their expressed concern and their recommended treatment plan. We control for physician demographics (like age, gender, and religiosity), patient population, and geography. Physician partisan bias can lead to unwarranted variation in patient care. Awareness of how a physician's political attitudes might affect patient care is important to physicians and patients alike.
Democratic and Republican physicians provide different care on politicized health issues

PubMed Central

Hersh, Eitan D.; Goldenberg, Matthew N.

2016-01-01

Physicians frequently interact with patients about politically salient health issues, such as drug use, firearm safety, and sexual behavior. We investigate whether physicians’ own political views affect their treatment decisions on these issues. We linked the records of over 20,000 primary care physicians in 29 US states to a voter registration database, obtaining the physicians’ political party affiliations. We then surveyed a sample of Democratic and Republican primary care physicians. Respondents evaluated nine patient vignettes, three of which addressed especially politicized health issues (marijuana, abortion, and firearm storage). Physicians rated the seriousness of the issue presented in each vignette and their likelihood of engaging in specific management options. On the politicized health issues—and only on such issues—Democratic and Republican physicians differed substantially in their expressed concern and their recommended treatment plan. We control for physician demographics (like age, gender, and religiosity), patient population, and geography. Physician partisan bias can lead to unwarranted variation in patient care. Awareness of how a physician’s political attitudes might affect patient care is important to physicians and patients alike. PMID:27698126
Does Social Health Insurance Close the Gap: The Case of Socioeconomic Status and Preterm Low-Birth-Weight Survival.

PubMed

Hsieh, Vivian Chia-Rong; Shieh, Shwn-Huey; Chen, Chiu-Ying; Liou, Saou-Hsing; Hsiao, Yu-Chen; Wu, Trong-Neng

2015-07-01

Using a retrospective cohort study design, we report empirical evidence on the effect of parental socioeconomic status, primary care, and health care expenditure associated with preterm or low-birth-weight (PLBW) babies on their mortality (neonatal, postneonatal, and under-5 mortality) under a universal health care system. A total of 4668 singleton PLBW babies born in Taiwan between January 1 and December 31, 2001, are extracted from a population-based medical claims database for a follow-up of up to 5 years. Multivariate survival models suggest the positive effect of higher parental income is significant in neonatal period but diminishes in later stages. Consistent inverse relationship is observed between adequate antenatal care and the three outcomes: neonatal hazard ratio (HR) = 0.494, 95% confidence interval (CI) = 0.312 to 0.783; postneonatal HR = 0.282, 95% CI = 0.102 to 0.774; and under-5 HR = 0.575, 95% CI = 0.386 to 0.857. Primary care services uptake should be actively promoted, particularly in lower income groups, to prevent premature PLBW mortality. © 2015 APJPH.
Navigating the legal and ethical foundations of informed consent and confidentiality in integrated primary care.

PubMed

Hudgins, Cathy; Rose, Sandra; Fifield, Peter Y; Arnault, Steve

2013-03-01

This article describes findings from ongoing research and analysis of current literature in addition to discussions with leaders in the field, communications with lawyers and administrators of advocacy and government agencies pertaining to integrated primary care (IPC). Standards of care are established based on a myriad of factors, including professional codes of ethics, case law, state and federal laws, professional standards, existing best practices, current professional guidelines, administrative rules and regulations, and licensing board regulations. Regulations may differ for behavioral health and medical providers, posing challenges in IPC settings. This article provides a review of these regulations, particularly 42CFR Part 2, a federal law governing confidentiality for substance abuse programs, Health Insurance Portability and Accountability Act (HIPAA), and state laws relevant to patient care in IPC settings. On the basis of findings from the study, the authors make recommendations related to patient care practices concerning informed consent and release of information procedures, treatment and warm hand-off protocols, documentation and electronic record keeping, agreements with other providers, and billing. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Improving burn care and preventing burns by establishing a burn database in Ukraine.

PubMed

Fuzaylov, Gennadiy; Murthy, Sushila; Dunaev, Alexander; Savchyn, Vasyl; Knittel, Justin; Zabolotina, Olga; Dylewski, Maggie L; Driscoll, Daniel N

2014-08-01

Burns are a challenge for trauma care and a contribution to the surgical burden. The former Soviet republic of Ukraine has a foundation for burn care; however data concerning burns in Ukraine has historically been scant. The objective of this paper was to compare a new burn database to identify problems and implement improvements in burn care and prevention in this country. Retrospective analyses of demographic and clinical data of burn patients including Tukey's post hoc test, analysis of variance, and chi square analyses, and Fisher's exact test were used. Data were compared to the American Burn Association (ABA) burn repository. This study included 1752 thermally injured patients treated in 20 hospitals including Specialized Burn Unit in Municipal Hospital #8 Lviv, Lviv province in Ukraine. Scald burns were the primary etiology of burns injuries (70%) and burns were more common among children less than five years of age (34%). Length of stay, mechanical ventilation use, infection rates, and morbidity increased with greater burn size. Mortality was significantly related to burn size, inhalation injury, age, and length of stay. Wound infections were associated with burn size and older age. Compared to ABA data, Ukrainian patients had double the length of stay and a higher rate of wound infections (16% vs. 2.4%). We created one of the first burn databases from a region of the former Soviet Union in an effort to bring attention to burn injury and improve burn care. Copyright © 2013 Elsevier Ltd and ISBI. All rights reserved.

Economic analysis of Heart and Stroke Foundation of Ontario’s Hypertension Management Initiative

PubMed Central

de Oliveira, Claire; Wijeysundera, Harindra C; Tobe, Sheldon W; Lum-Kwong, Margaret Moy; Von Sychowski, Shirley; Wang, Xuesong; Tu, Jack V; Krahn, Murray D

2012-01-01

Objectives Hypertension is suboptimally treated in primary care settings. We evaluated the cost-effectiveness of the Heart and Stroke Foundation of Ontario’s Hypertension Management Initiative (HMI), an interdisciplinary, evidence-informed chronic disease management model for primary care that focuses on improving blood pressure management and control by primary care providers and patients according to clinical best practice guidelines. Methods The perspective of our analysis was that of the Ontario Ministry of Health and Long-Term Care with a lifetime horizon and 5% annual discount rate. Using data from a prospective cohort study from the HMI, we created two matched groups: pre-HMI (standard care), and post-HMI (n = 1720). For each patient, we estimated the 10-year risk of cardiovascular disease (CVD) using the Framingham risk equation and life expectancy from life tables. Long-term health care costs incurred with physician visits, acute and chronic care hospitalizations, emergency department visits, same-day surgeries, and medication use were determined through linkage to administrative databases, using a bottom-up approach. Results The HMI intervention was associated with significant reductions in systolic blood pressure (126 mmHg vs 134 mmHg with standard care; P-value < 0.001). These improvements were associated with a reduction in the 10-year risk of CVD (9.5% risk vs 10.7% in standard care; P-value < 0.001) and a statistically significant improvement in discounted life expectancy (9.536 years vs 9.516 in standard care; P-value < 0.001). The HMI cohort had a discounted mean lifetime cost of $22,884 CAD vs $22,786 CAD for standard care, with an incremental cost-effectiveness ratio of $4939 CAD per life-year gained. Conclusion We found that the HMI is a cost-effective means of providing evidence-informed, chronic disease management in primary care to patients with hypertension. PMID:23180969
A THIRD OF PATIENTS TREATED AT A TERTIARY LEVEL SURGICAL SERVICE COULD BE TREATED AT A SECONDARY LEVEL FACILITY.

PubMed

Van Straten, S K; Stannard, C J; Bulabula, J; Paul, K; Leong, J; Klipin, M

2017-06-01

South Africa has an overburdened public healthcare system. Some admissions to Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) may not require tertiary care. The numbers and details thereof are uncertain. Clinical research is limited by skills and access to data. A retrospective analysis of Electronic Discharge (ED) summaries from the Department of Surgery at CMJAH between 01 April 2015 and 01 April 2016. An SQL-query of the database generated a .csv file of all discharges with the fields database reference number, length of stay and level of care. The details and level of care of each record were verified by MBBCh 5 medical students using a defined level of care template with review of the full discharge summary. The data was reviewed by a senior clinician. There were 3007 discharge summaries, 97 were not classifiable, two were test records and one was a duplicate. These 100 records were excluded. There were no primary level records. Secondary level patients represented 29% (854) of patients discharged and 19% of total bed days. Tertiary and quaternary together represented 71% of the total patients and 81% of bed days. The average length of stay was 4.31 days for secondary, 6.98 days for tertiary and 9.77 days for quaternary level of care allocation. Almost a third (29%) of patients discharged from CMJAH Department of Surgery were deemed suitable for secondary level care. These admissions have a shorter length of stay and comprise 19% of total bed days. Students and electronic databases are useful research resources.
A standardised graphic method for describing data privacy frameworks in primary care research using a flexible zone model.

PubMed

Kuchinke, Wolfgang; Ohmann, Christian; Verheij, Robert A; van Veen, Evert-Ben; Arvanitis, Theodoros N; Taweel, Adel; Delaney, Brendan C

2014-12-01

To develop a model describing core concepts and principles of data flow, data privacy and confidentiality, in a simple and flexible way, using concise process descriptions and a diagrammatic notation applied to research workflow processes. The model should help to generate robust data privacy frameworks for research done with patient data. Based on an exploration of EU legal requirements for data protection and privacy, data access policies, and existing privacy frameworks of research projects, basic concepts and common processes were extracted, described and incorporated into a model with a formal graphical representation and a standardised notation. The Unified Modelling Language (UML) notation was enriched by workflow and own symbols to enable the representation of extended data flow requirements, data privacy and data security requirements, privacy enhancing techniques (PET) and to allow privacy threat analysis for research scenarios. Our model is built upon the concept of three privacy zones (Care Zone, Non-care Zone and Research Zone) containing databases, data transformation operators, such as data linkers and privacy filters. Using these model components, a risk gradient for moving data from a zone of high risk for patient identification to a zone of low risk can be described. The model was applied to the analysis of data flows in several general clinical research use cases and two research scenarios from the TRANSFoRm project (e.g., finding patients for clinical research and linkage of databases). The model was validated by representing research done with the NIVEL Primary Care Database in the Netherlands. The model allows analysis of data privacy and confidentiality issues for research with patient data in a structured way and provides a framework to specify a privacy compliant data flow, to communicate privacy requirements and to identify weak points for an adequate implementation of data privacy. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Improving Care for Patients With or at Risk for Chronic Kidney Disease Using Electronic Medical Record Interventions: A Pragmatic Cluster-Randomized Trial Protocol

PubMed Central

Nash, Danielle M.; Ivers, Noah M.; Young, Jacqueline; Jaakkimainen, R. Liisa; Garg, Amit X.; Tu, Karen

2017-01-01

Background: Many patients with or at risk for chronic kidney disease (CKD) in the primary care setting are not receiving recommended care. Objective: The objective of this study is to determine whether a multifaceted, low-cost intervention compared with usual care improves the care of patients with or at risk for CKD in the primary care setting. Design: A pragmatic cluster-randomized trial, with an embedded qualitative process evaluation, will be conducted. Setting: The study population comes from the Electronic Medical Record Administrative data Linked Database®, which includes clinical data for more than 140 000 rostered adults cared for by 194 family physicians in 34 clinics across Ontario, Canada. The 34 primary care clinics will be randomized to the intervention or control group. Intervention: The intervention group will receive resources from the “CKD toolkit” to help improve care including practice audit and feedback, printed educational materials for physicians and patients, electronic decision support and reminders, and implementation support. Measurements: Patients with or at risk for CKD within participating clinics will be identified using laboratory data in the electronic medical records. Outcomes will be assessed after dissemination of the CKD tools and after 2 rounds of feedback on performance on quality indicators have been sent to the physicians using information from the electronic medical records. The primary outcome is the proportion of patients aged 50 to 80 years with nondialysis-dependent CKD who are on a statin. Secondary outcomes include process of care measures such as screening tests, CKD recognition, monitoring tests, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker prescriptions, blood pressure targets met, and nephrologist referral. Hierarchical analytic modeling will be performed to account for clustering. Semistructured interviews will be conducted with a random purposeful sample of physicians in the intervention group to understand why the intervention achieved the observed effects. Conclusions: If our intervention improves care, then the CKD toolkit can be adapted and scaled for use in other primary care clinics which use electronic medical records. Trial Registration: ClinicalTrials.gov Identifier: NCT02274298 PMID:28607686
Telemedicine with clinical decision support for critical care: a systematic review.

PubMed

Mackintosh, Nicola; Terblanche, Marius; Maharaj, Ritesh; Xyrichis, Andreas; Franklin, Karen; Keddie, Jamie; Larkins, Emily; Maslen, Anna; Skinner, James; Newman, Samuel; De Sousa Magalhaes, Joana Hiew; Sandall, Jane

2016-10-18

Telemedicine applications aim to address variance in clinical outcomes and increase access to specialist expertise. Despite widespread implementation, there is little robust evidence about cost-effectiveness, clinical benefits, and impact on quality and safety of critical care telemedicine. The primary objective was to determine the impact of critical care telemedicine (with clinical decision support available 24/7) on intensive care unit (ICU) and hospital mortality and length of stay in adults and children. The secondary objectives included staff and patient experience, costs, protocol adherence, and adverse events. Data sources included MEDLINE, EMBASE, CINAHL, Cochrane Library databases, Health Technology Assessment Database, Web of Science, OpenGrey, OpenDOAR, and the HMIC through to December 2015. Randomised controlled trials and quasi-experimental studies were eligible for inclusion. Eligible studies reported on differences between groups using the telemedicine intervention and standard care. Two review authors screened abstracts and assessed potentially eligible studies using Cochrane guidance. Two controlled before-after studies met the inclusion criteria. Both were assessed as high risk of bias. Meta-analysis was not possible as we were unable to disaggregate data between the two studies. One study used a non-randomised stepped-wedge design in seven ICUs. Hospital mortality was the primary outcome which showed a reduction from 13.6 % (CI, 11.9-15.4 %) to 11.8 % (CI, 10.9-12.8 %) during the intervention period with an adjusted odds ratio (OR) of 0.40 (95 % CI, 0.31-0.52; p = .005). The second study used a non-randomised, unblinded, pre-/post-assessment of telemedicine interventions in 56 adult ICUs. Hospital mortality (primary outcome) reduced from 11 to 10 % (adjusted hazard ratio (HR) = 0.84; CI, 0.78-0.89; p = <.001). This review highlights the poor methodological quality of most studies investigating critical care telemedicine. The results of the two included studies showed a reduction in hospital mortality in patients receiving the intervention. Further multi-site randomised controlled trials or quasi-experimental studies with accompanying process evaluations are urgently needed to determine effectiveness, implementation, and associated costs. PROSPERO CRD42014007406.
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
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
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.
Clinical validity of a population database definition of remission in patients with major depression.

PubMed

Sicras-Mainar, Antoni; Blanca-Tamayo, Milagrosa; Gutiérrez-Nicuesa, Laura; Salvatella-Pasant, Jordi; Navarro-Artieda, Ruth

2010-02-11

Major depression (MD) is one of the most frequent diagnoses in Primary Care. It is a disabling illness that increases the use of health resources. To describe the concordance between remission according to clinical assessment and remission obtained from the computerized prescription databases of patients with MD in a Spanish population. multicenter cross-sectional. The population under study was comprised of people from six primary care facilities, who had a MD episode between January 2003 and March 2007. A specialist in psychiatry assessed a random sample of patient histories and determined whether a certain patient was in remission according to clinical criteria (ICPC-2). Regarding the databases, patients were considered in remission when they did not need further prescriptions of AD for at least 6 months after completing treatment for a new episode. Validity indicators (sensitivity [S], specificity [Sp]) and clinical utility (positive and negative probability ratio [PPR] and [NPR]) were calculated. The concordance index was established using Cohen's kappa coefficient. Significance level was p < 0.05. 133 patient histories were reviewed. The kappa coefficient was 82.8% (confidence intervals [CI] were 95%: 73.1 - 92.6), PPR 9.8% and NPR 0.1%. Allocation discrepancies between both criteria were found in 11 patients. S was 92.5% (CI was 95%: 88.0 - 96.9%) and Sp was 90.6% (CI was 95%: 85.6 - 95.6%), p < 0.001. Reliability analysis: Cronbach's alpha: 90.6% (CI was 95%: 85.6 - 95.6%). Results show an acceptable level of concordance between remission obtained from the computerized databases and clinical criteria. The major discrepancies were found in diagnostic accuracy.
Can the feedback of patient assessments, brief training, or their combination, improve the interpersonal skills of primary care physicians? A systematic review.

PubMed

Cheraghi-Sohi, Sudeh; Bower, Peter

2008-08-21

Improving quality of primary care is a key focus of international health policy. Current quality improvement efforts place a large focus on technical, clinical aspects of quality, but a comprehensive approach to quality improvement should also include interpersonal care. Two methods of improving the quality of interpersonal care in primary care have been proposed. One involves the feedback of patient assessments of interpersonal care to physicians, and the other involves brief training and education programmes. This study therefore reviewed the efficacy of (i) feedback of real patient assessments of interpersonal care skills, (ii) brief training focused on the improvement of interpersonal care (iii) interventions combining both (i) and (ii) Systematic review of randomised controlled trials. Three electronic databases were searched (CENTRAL, Medline and Embase) and augmented by searches of the bibliographies of retrieved articles. The quality of studies was appraised and results summarised in narrative form. Nine studies were included (two patient based feedback studies and seven brief training studies). Of the two feedback studies, one reported a significant positive effect. Only one training study reported a significant positive effect. There is limited evidence concerning the effects of patient based feedback. There is reasonable evidence that brief training as currently delivered is not effective, although the evidence is not definitive, due to the small number of trials and the variation in the training methods and goals. The lack of effectiveness of these methods may reflect a number of issues, such as differences in the effectiveness of the interventions in experienced practitioners and those in training, the lack of theory linking feedback to behaviour change, failure to provide sufficient training or to use a comprehensive range of behaviour change techniques. Further research into both feedback and brief training interventions is required before these interventions are routinely introduced to improve patient satisfaction with interpersonal care in primary care. The interventions to be tested in future research should consider using insights from the wider literature on communication outside primary care, might benefit from a clearer theoretical basis, and should examine the use of combined brief training and feedback.
Implementation and maintenance of patient navigation programs linking primary care with community-based health and social services: a scoping literature review.

PubMed

Valaitis, Ruta K; Carter, Nancy; Lam, Annie; Nicholl, Jennifer; Feather, Janice; Cleghorn, Laura

2017-02-06

Since the early 90s, patient navigation programs were introduced in the United States to address inequitable access to cancer care. Programs have since expanded internationally and in scope. The goals of patient navigation programs are to: a) link patients and families to primary care services, specialist care, and community-based health and social services (CBHSS); b) provide more holistic patient-centred care; and, c) identify and resolve patient barriers to care. This paper fills a gap in knowledge to reveal what is known about motivators and factors influencing implementation and maintenance of patient navigation programs in primary care that link patients to CBHSS. It also reports on outcomes from these studies to help identify gaps in research that can inform future studies. This scoping literature review involved: i) electronic database searches; ii) a web site search; iii) a search of reference lists from literature reviews; and, iv) author follow up. It included papers from Canada, the United States, the United Kingdom, Australia, New Zealand, and/or Western Europe published between January 1990 and June 2013 if they discussed navigators or navigation programs in primary care settings that linked patients to CBHSS. Of 34 papers, most originated in the United States (n = 29) while the remainder were from the United Kingdom, Canada and Australia. Motivators for initiating navigation programs were to: a) improve delivery of health and social care services; b) support and manage specific health needs or specific population needs, and; c) improve quality of life and wellbeing of patients. Eleven factors were found to influence implementation and maintenance of these patient navigation programs. These factors closely aligned with the Diffusion of Innovation in Service Organizations model, thus providing a theoretical foundation to support them. Various positive outcomes were reported for patients, providers and navigators, as well as the health and social care system, although they need to be considered with caution since the majority of studies were descriptive. This study contributes new knowledge that can inform the initiation and maintenance of primary care patient navigation programs that link patients with CBHSS. It also provides directions for future research.
Evaluation of primary care midwifery in The Netherlands: design and rationale of a dynamic cohort study (DELIVER).

PubMed

Manniën, Judith; Klomp, Trudy; Wiegers, Therese; Pereboom, Monique; Brug, Johannes; de Jonge, Ank; van der Meijde, Margreeth; Hutton, Eileen; Schellevis, Francois; Spelten, Evelien

2012-03-20

In the Netherlands, midwives are autonomous medical practitioners and 78% of pregnant women start their maternity care with a primary care midwife. Scientific research to support evidence-based practice in primary care midwifery in the Netherlands has been sparse. This paper describes the research design and methodology of the multicenter multidisciplinary prospective DELIVER study which is the first large-scale study evaluating the quality and provision of primary midwifery care. Between September 2009 and April 2011, data were collected from clients and their partners, midwives and other healthcare professionals across the Netherlands. Clients from twenty midwifery practices received up to three questionnaires to assess the expectations and experiences of clients (e.g. quality of care, prenatal screening, emotions, health, and lifestyle). These client data were linked to data from the Netherlands Perinatal Register and electronic client records kept by midwives. Midwives and practice assistants from the twenty participating practices recorded work-related activities in a diary for one week, to assess workload. Besides, the midwives were asked to complete a questionnaire, to gain insight into collaboration of midwives with other care providers, their tasks and attitude towards their job, and the quality of the care they provide. Another questionnaire was sent to all Dutch midwifery practices which reveals information regarding the organisation of midwifery practices, provision of preconception care, collaboration with other care providers, and provision of care to ethnic minorities. Data at client, midwife and practice level can be linked. Additionally, partners of pregnant women and other care providers were asked about their expectations and experiences regarding the care delivered by midwives and in six practices client consults were videotaped to objectively assess daily practice. In total, 7685 clients completed at least one questionnaire, 136 midwives and assistants completed a diary with work-related activities (response 100%), 99 midwives completed a questionnaire (92%), and 319 practices across the country completed a questionnaire (61%), 30 partners of clients participated in focus groups, 21 other care providers were interviewed and 305 consults at six midwifery practices were videotaped.The multicenter DELIVER study provides an extensive database with national representative data on the quality of primary care midwifery in the Netherlands. This study will support evidence-based practice in primary care midwifery in the Netherlands and contribute to a better understanding of the maternity care system. © 2012 Manniën et al; licensee BioMed Central Ltd.
Development of a decision support tool for primary care management of patients with abnormal liver function tests without clinically apparent liver disease: a record-linkage population cohort study and decision analysis (ALFIE).

PubMed

Donnan, P T; McLernon, D; Dillon, J F; Ryder, S; Roderick, P; Sullivan, F; Rosenberg, W

2009-04-01

To determine the natural history of abnormalities in liver function tests (LFTs), derive predictive algorithms for liver disease and identify the most cost-effective strategies for further investigation. MEDLINE database from 1966 to September 2006, EMBASE, CINAHL and the Cochrane Library. Population-based retrospective cohort study set in primary care in Tayside, Scotland, between 1989 and 2003. Participants were patients with no obvious signs of liver disease and registered with a general practitioner (GP). The study followed up those with an incident batch of LFTs in primary care to subsequent liver disease or mortality over a maximum of 15 years. The health technologies being assessed were primary care LFTs, viral and autoantibody tests, ultrasound and liver biopsy. Measures used were the epidemiology of liver disease in Tayside (ELDIT) database, time-to-event modelling, predictive algorithms derived using the Weibull survival model, decision analyses from an NHS perspective, cost-utility analyses, and one-way and two-way sensitivity analyses. A total of 95,977 patients had 364,194 initial LFTs, with a median follow-up of 3.7 years. Of these, 21.7% had at least one abnormal liver function test (ALFT) and 1090 (1.14%) developed liver disease. Elevated transaminases were strongly associated with diagnosed liver disease, with hazard ratios (HRs) of 4.23 [95% CI (confidence interval) 3.55-5.04] for mild levels and 12.67 (95% CI 9.74-16.47) for severe levels versus normal. For gamma-glutamyltransferase (GGT), these HRs were 2.54 (95% CI 2.17-2.96) and 13.44 (10.71-16.87) respectively. Low albumin was strongly associated with all cause mortality, with ratios of 2.65 (95% CI 2.47-2.85) for mild levels and 4.99 (95% CI 4.26-5.84) for severe levels. Sensitivity for predicting events over 5 years was low and specificity was high. Follow-up time was split into baseline to 3 months, 3 months to 1 year and over 1 year. All LFTs were predictive of liver disease, and high probability of liver disease was associated with being female, methadone use, alcohol dependency and deprivation. The shorter-term models had overall c-statistics of 0.85 and 0.72 for outcome of liver disease at 3 months and 1 year respectively, and 0.88 and 0.82 for all cause mortality at 3 months and 1 year respectively. Calibration was good for models predicting liver disease. Discrimination was low for models predicting events at over 1 year. In cost-utility analyses, retesting dominated referral as an option. However, using the predictive algorithms to identify the top percentile at high risk of liver disease, retesting had an incremental cost-utility ratio of 7588 pounds relative to referral. GGT should be included in the batch of LFTs in primary care. If the patient in primary care has no obvious liver disease and a low or moderate risk of liver disease, retesting in primary care is the most cost-effective option. If the patient with ALFTs in primary care has a high risk of liver disease, retesting depends on the willingness to pay of the NHS. Cut-offs are arbitrary and in developing decision aids it is important to treat the LFT results as continuous variables.
The influence of international medical electives on career preference for primary care and rural practice.

PubMed

Law, Iain R; Walters, Lucie

2015-11-11

Previous studies have demonstrated a correlation between medical students who undertake international medical electives (IMEs) in resource poor settings and their reported career preference for primary care in underserved areas such as rural practice. This study examines whether a similar correlation exists in the Australian medical school context. Data was extracted from the Medical Schools Outcomes Database (MSOD) of Australian medical students that completed commencing student and exit questionnaires between 2006 and 2011. Student responses were categorized according to preferred training program and preferred region of practice at commencement. The reported preferences at exit of students completing IMEs in low and middle income countries (LMIC) were compared to those completing electives in high income countries (HIC). The effect of elective experience for students expressing a preference for primary care at commencement was non-significant, with 40.32 % of LMIC and 42.11 % of HIC students maintaining a preference for primary care. Similarly there were no significant changes following LMIC electives for students expressing a preference for specialist training at commencement with 11.81 % of LMIC and 10.23 % of HIC students preferring primary care at exit. The effect of elective experience for students expressing a preference for rural practice at commencement was non-significant, with 41.51 % of LMIC and 49.09 % of HIC students preferring rural practice at exit. Similarly there were no significant changes following LMIC electives for students expressing a preference for urban practice at commencement, with 7.84 % of LMIC and 6.70 % of HIC students preferring rural practice at exit. This study did not demonstrate an association between elective experience in resource poor settings and a preference for primary care or rural practice. This suggests that the previously observed correlation between LMIC electives and interest in primary care in disadvantaged communities is likely dependent on student and elective program characteristics and supports the need for further research and critical examination of elective programs at Australian medical schools.
[Concordance in the registry of dementia among the main sources of clinical information].

PubMed

Marta-Moreno, Javier; Obón-Azuara, Blanca; Gimeno-Felíu, Luis; Achkar-Tuglaman, Nesib Nicolás; Poblador-Plou, Beatriz; Calderón-Larrañaga, Amaia; Prados-Torres, Alexandra

2016-01-01

The objective of this work was to analyse the concordance in the registry of dementia among the main sources of clinical information, with the aim of determining their usefulness for epidemiological and clinical research. Descriptive study of patients assigned to the Aragon Health Service in 2010 (n=1,344,891). (i)the pharmacy billing database (n=9,392); (ii)Primary Care electronic health records (EHR) (n=9,471), and (iii)the hospital minimum basic data set (n=3,289). When studying the concordance of the databases, the group of patients with a specific treatment for dementia (i.e., acetylcholinesterase inhibitors and/or memantine) was taken as the reference. The diagnosis in Primary Care was missing for 47.3% of patients taking anti-dementia drugs. The same occurred with 38.3% of dementia patients admitted to hospital during the study year. Among patients with a diagnosis of dementia in the EHR, only half (52.3%) was under treatment for this condition. This percentage decreased to 34.4% in patients with the diagnosis registered in the hospital database. The weak concordance in the registry of the dementia diagnosis between the main health information systems makes their use and analysis more complex, and supports the need to include all available health data sources in order to gain a global picture of the epidemiological and clinical reality of this health condition. Copyright © 2015 SEGG. Publicado por Elsevier España, S.L.U. All rights reserved.
Service utilization following participation in cognitive processing therapy or prolonged exposure therapy for post-traumatic stress disorder.

PubMed

Meyers, Laura L; Strom, Thad Q; Leskela, Jennie; Thuras, Paul; Kehle-Forbes, Shannon M; Curry, Kyle T

2013-01-01

This study evaluated the impact of a course of prolonged exposure or cognitive processing therapy on mental health and medical service utilization and health care service costs provided by the Department of Veterans Affairs (VA). Data on VA health service utilization and health care costs were obtained from national VA databases for 70 veterans who completed prolonged exposure or cognitive processing therapy at a Midwestern VA medical center. Utilization of services and cost data were examined for the year before and after treatment. Results demonstrated a significant decrease in the use of individual and group psychotherapy. Direct costs associated with mental health care decreased by 39.4%. Primary care and emergency department services remained unchanged.
Reasons for non-adherence to cardiometabolic medications, and acceptability of an interactive voice response intervention in patients with hypertension and type 2 diabetes in primary care: a qualitative study

PubMed Central

Sutton, Stephen

2017-01-01

Objectives This study explored the reasons for patients’ non-adherence to cardiometabolic medications, and tested the acceptability of the interactive voice response (IVR) as a way to address these reasons, and support patients, between primary care consultations. Design, method, participants and setting The study included face-to-face interviews with 19 patients with hypertension and/or type 2 diabetes mellitus, selected from primary care databases, and presumed to be non-adherent. Thirteen of these patients pretested elements of the IVR intervention few months later, using a think-aloud protocol. Five practice nurses were interviewed. Data were analysed using multiperspective, and longitudinalthematic analysis. Results Negative beliefs about taking medications, the complexity of prescribed medication regimens, and the limited ability to cope with the underlying affective state, within challenging contexts, were mentioned as important reasons for non-adherence. Nurses reported time constraints to address each patient’s different reasons for non-adherence, and limited efficacy to support patients, between primary care consultations. Patients gave positive experiential feedback about the IVR messages as a way to support them take their medicines, and provided recommendations for intervention content and delivery mode. Specifically, they liked the voice delivering the messages and the voice recognition software. For intervention content, they preferred messages that were tailored, and included messages with ‘information about health consequences’, ‘action plans’, or simple reminders for performing the behaviour. Conclusions Patients with hypertension and/or type 2 diabetes, and practice nurses, suggested messages tailored to each patient’s reasons for non-adherence. Participants recommended IVR as an acceptable platform to support adherence to cardiometabolic medications between primary care consultations. Future studies could usefully test the acceptability, and feasibility, of tailored IVR interventions to support medication adherence, as an adjunct to primary care. PMID:28801402
Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence.

PubMed

Phillips, Christine B; Pearce, Christopher M; Hall, Sally; Travaglia, Joanne; de Lusignan, Simon; Love, Tom; Kljakovic, Marjan

2010-11-15

To review the literature on different models of clinical governance and to explore their relevance to Australian primary health care, and their potential contributions on quality and safety. 25 electronic databases, scanning reference lists of articles and consultation with experts in the field. We searched publications in English after 1999, but a search of the German language literature for a specific model type was also undertaken. The grey literature was explored through a hand search of the medical trade press and websites of relevant national and international clearing houses and professional or industry bodies. 11 software packages commonly used in Australian general practice were reviewed for any potential contribution to clinical governance. 19 high-quality studies that assessed outcomes were included. All abstracts were screened by one researcher, and 10% were screened by a second researcher to crosscheck screening quality. Studies were reviewed and coded by four reviewers, with all studies being rated using standard critical appraisal tools such as the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Two researchers reviewed the Australian general practice software. Interviews were conducted with 16 informants representing service, regional primary health care, national and international perspectives. Most evidence supports governance models which use targeted, peer-led feedback on the clinician's own practice. Strategies most used in clinical governance models were audit, performance against indicators, and peer-led reflection on evidence or performance. The evidence base for clinical governance is fragmented, and focuses mainly on process rather than outcomes. Few publications address models that enhance safety, efficiency, sustainability and the economics of primary health care. Locally relevant clinical indicators, the use of computerised medical record systems, regional primary health care organisations that have the capacity to support the uptake of clinical governance at the practice level, and learning from the Aboriginal community-controlled sector will help integrate clinical governance into primary care.
[Physical therapy in pediatric primary care: a review of experiences].

PubMed

de Sá, Miriam Ribeiro Calheiros; Thomazinho, Paula de Almeida; Santos, Fabiano Luiz; Cavalcanti, Nicolette Celani; Ribeiro, Carla Trevisan Martins; Negreiros, Maria Fernanda Vieira; Vinhaes, Marcia Regina

2014-11-01

To review pediatric physical therapy experiences described in the literature and to analyze the production of knowledge on physical therapy in the context of pediatric primary health care (PPHC). A systematic review was conducted according to the PRISMA criteria. The following databases were searched: MEDLINE, LILACS, SciELO, PubMed, Scopus and Cochrane; Brazilian Ministry of Health's CAPES doctoral dissertations database; and System for Information on Grey Literature in Europe (SIGLE). The following search terms were used: ["primary health care" and ("physical therapy" or "physiotherapy") and ("child" or "infant")] and equivalent terms in Portuguese and Spanish, with no restriction on publication year. Thirteen articles from six countries were analyzed and grouped into three main themes: professional dilemmas (three articles), specific competencies and skills required in a PPHC setting (seven articles), and practice reports (four articles). Professional dilemmas involved expanding the role of physical therapists to encompass community environments and sharing the decision-making process with the family, as well as collaborative work with other health services to identify the needs of children. The competencies and skills mentioned in the literature related to the identification of clinical and sociocultural symptoms that go beyond musculoskeletal conditions, the establishment of early physical therapy diagnoses, prevention of overmedication, and the ability to work as team players. Practice reports addressed stimulation in children with neurological diseases, respiratory treatment, and establishing groups with mothers of children with these conditions. The small number of studies identified in this review suggests that there is little knowledge regarding the roles of physical therapists in PPHC and possibly regarding the professional abilities required in this setting. Therefore, further studies are required to provide data on the field, along with a continuing education effort on the part of physical therapists.
The laboratory-clinician team: a professional call to action to improve communication and collaboration for optimal patient care in chromosomal microarray testing.

PubMed

Wain, Karen E; Riggs, Erin; Hanson, Karen; Savage, Melissa; Riethmaier, Darlene; Muirhead, Andrea; Mitchell, Elyse; Packard, Bethanny Smith; Faucett, W Andrew

2012-10-01

The International Standards for Cytogenomic Arrays (ISCA) Consortium is a worldwide collaborative effort dedicated to optimizing patient care by improving the quality of chromosomal microarray testing. The primary effort of the ISCA Consortium has been the development of a database of copy number variants (CNVs) identified during the course of clinical microarray testing. This database is a powerful resource for clinicians, laboratories, and researchers, and can be utilized for a variety of applications, such as facilitating standardized interpretations of certain CNVs across laboratories or providing phenotypic information for counseling purposes when published data is sparse. A recognized limitation to the clinical utility of this database, however, is the quality of clinical information available for each patient. Clinical genetic counselors are uniquely suited to facilitate the communication of this information to the laboratory by virtue of their existing clinical responsibilities, case management skills, and appreciation of the evolving nature of scientific knowledge. We intend to highlight the critical role that genetic counselors play in ensuring optimal patient care through contributing to the clinical utility of the ISCA Consortium's database, as well as the quality of individual patient microarray reports provided by contributing laboratories. Current tools, paper and electronic forms, created to maximize this collaboration are shared. In addition to making a professional commitment to providing complete clinical information, genetic counselors are invited to become ISCA members and to become involved in the discussions and initiatives within the Consortium.

Town and Gown Differences Among the 100 Largest Medical Groups in the United States.

PubMed

Welch, W Pete; Bindman, Andrew B

2016-07-01

The authors undertook a study to determine whether large academic and community-based medical groups differ in terms of their financial stake in Medicare Advantage or Medicare Accountable Care Organizations (ACOs) and whether their participation in these alternative payment models is related to their size, specialty mix, and Medicare physician market share in their local area. The authors used the 2013 Medicare Data on Provider Practice and Specialty database and a national database of ACOs to conduct a cross-sectional descriptive study of the 100 largest medical groups in the United States. Medical groups were categorized as academic or community based on matches of their name with a list of U.S. medical schools or the results of a series of Internet search procedures. Sixty-eight of the 100 largest groups were academic, and 32 were community based. On average, community-based groups had more than twice the percentage of primary care physicians as academic groups (mean, 38.4%; 95% CI, 34.7%-42.0%; vs. 18.3%; 95% CI, 17.0%-19.6%). Community groups were significantly (P < .001) more likely than academic groups to have a financial stake in a Medicare ACO or Medicare Advantage plan, but this difference was no longer significant when the percentage of primary care physicians in the group was added to the model. The specialty mix within academic medical groups may hinder their ability to transform themselves into organizations that can manage the financial responsibilities of caring for a patient population through a Medicare ACO or Medicare Advantage.
Understanding the implementation of interventions to improve the management of chronic kidney disease in primary care: a rapid realist review.

PubMed

Tsang, Jung Yin; Blakeman, Tom; Hegarty, Janet; Humphreys, John; Harvey, Gill

2016-04-04

Chronic kidney disease (CKD) is common and a significant marker of morbidity and mortality. Its management in primary care is essential for maintenance of cardiovascular health, avoidance of acute kidney injury (AKI) and delay in progression to end-stage renal disease. Although many guidelines and interventions have been established, there is global evidence of an implementation gap, including variable identification rates and low patient communication and awareness. The objective of this study is to understand the factors enabling and constraining the implementation of CKD interventions in primary care. A rapid realist review was conducted that involved a primary literature search of three databases to identify existing CKD interventions in primary care between the years 2000 and 2014. A secondary search was performed as an iterative process and included bibliographic and grey literature searches of reference lists, authors and research groups. A systematic approach to data extraction using Normalisation Process Theory (NPT) illuminated key mechanisms and contextual factors that affected implementation. Our primary search returned 710 articles that were narrowed down to 18 relevant CKD interventions in primary care. Our findings suggested that effective management of resources (encompassing many types) was a significant contextual factor enabling or constraining the functioning of mechanisms. Three key intervention features were identified from the many that contributed to successful implementation. Firstly, it was important to frame CKD interventions appropriately, such as within the context of cardiovascular health and diabetes. This enabled buy-in and facilitated an understanding of the significance of CKD and the need for intervention. Secondly, interventions that were compatible with existing practices or patients' everyday lives were readily accepted. In contrast, new systems that could not be integrated were abandoned as they were viewed as inconvenient, generating more work. Thirdly, ownership of the feedback process allowed users to make individualised improvements to the intervention to suit their needs. Our rapid realist review identified mechanisms that need to be considered in order to optimise the implementation of interventions to improve the management of CKD in primary care. Further research into the factors that enable prolonged sustainability and cost-effectiveness is required for efficient resource utilisation.
Primary Care Physician Panel Size and Quality of Care: A Population-Based Study in Ontario, Canada.

PubMed

Dahrouge, Simone; Hogg, William; Younger, Jaime; Muggah, Elizabeth; Russell, Grant; Glazier, Richard H

2016-01-01

The purpose of this study was to determine the relationship between the number of patients under a primary care physician's care (panel size) and primary care quality indicators. We conducted a cross-sectional, population-based study of fee-for-service and capitated interprofessional and non-interprofessional primary health care practices in Ontario, Canada between April 2008 and March 2010, encompassing 4,195 physicians with panel sizes ≥1,200 serving 8.3 million patients. Data was extracted from multiple linked, health-related administrative databases and covered 16 quality indicators spanning 5 dimensions of care: access, continuity, comprehensiveness, and evidence-based indicators of cancer screening and chronic disease management. The likelihood of being up-to-date on cervical, colorectal, and breast cancer screening showed relative decreases of 7.9% (P <.001), 5.9% (P = .01), and 4.6% (P <.001), respectively, with increasing panel size (from 1,200 to 3,900). Eight chronic care indicators (4 medication-based and 4 screening-based) showed no significant association with panel size. The likelihood of individuals with a new diagnosis of congestive heart failure having an echocardiogram, however, increased by a relative 8.1% (P <.001) with higher panel size. Increasing panel size was also associated with a 10.8% relative increase in hospitalization rates for ambulatory-care-sensitive conditions (P = .04) and a 10.8% decrease in non-urgent emergency department visits (P = .004). Continuity was highest with medium panel sizes (P <.001), and comprehensiveness had a small decrease (P = .03) with increasing panel size. Increasing panel size was associated with small decreases in cancer screening, continuity, and comprehensiveness, but showed no consistent relationships with chronic disease management or access indicators. We found no panel size threshold above which quality of care suffered. © 2016 Annals of Family Medicine, Inc.
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.
Risk of Post-Discharge Venous Thromboembolism and Associated Mortality in General Surgery: A Population-Based Cohort Study Using Linked Hospital and Primary Care Data in England

PubMed Central

Bouras, George; Burns, Elaine Marie; Howell, Ann-Marie; Bottle, Alex; Athanasiou, Thanos; Darzi, Ara

2015-01-01

Background Trends towards day case surgery and enhanced recovery mean that postoperative venous thromboembolism (VTE) may increasingly arise after hospital discharge. However, hospital data alone are unable to capture adverse events that occur outside of the hospital setting. The National Institute for Health and Care Excellence has suggested the use of primary care data to quantify hospital care-related VTE. Data in surgical patients using these resources is lacking. The aim of this study was to measure VTE risk and associated mortality in general surgery using linked primary care and hospital databases, to improve our understanding of harm from VTE that arises beyond hospital stay. Methods This was a longitudinal cohort study using nationally linked primary care (Clinical Practice Research Datalink, CPRD), hospital administrative (Hospital Episodes Statistics, HES), population statistics (Office of National Statistics, ONS) and National Cancer Intelligence Network databases. Routinely collected information was used to quantify 90-day in-hospital VTE, 90-day post-discharge VTE and 90-day mortality in adults undergoing one of twelve general surgical procedures between 1st April 1997 and 31st March 2012. The earliest postoperative recording of deep vein thrombosis or pulmonary embolism in CPRD, HES and ONS was counted in each patient. Covariates from multiple datasets were combined to derive detailed prediction models for VTE and mortality. Limitation included the capture of VTE presenting to healthcare only and the lack of information on adherence to pharmacological thromboprophylaxis as there was no data linkage to hospital pharmacy records. Results There were 981 VTE events captured within 90 days of surgery in 168005 procedures (23.7/1000 patient-years). Overall, primary care data increased the detection of postoperative VTE by a factor of 1.38 (981/710) when compared with using HES and ONS only. Total VTE rates ranged between 3.2/1000 patient-years in haemorrhoidectomy to 118.3/1000 patient-years in esophagogastric resection. Predictors of VTE included emergency surgery (OR = 1.91 95%CI 1.60–2.28, p<0.001), age (OR = 1.02 95%CI 1.02–1.03, p<0.001), body mass index (OR = 1.03 95%CI 1.01–1.04, p<0.001), previous VTE (OR = 8.07 95%CI 6.61–9.83, p<0.001), length of stay (OR = 1.00 95%CI 1.00–1.00, p = 0.007) and cancer stages II (OR = 1.38 95%CI 1.03–1.87, p = 0.033), III (OR = 1.50 95%CI 1.11–2.01, p = 0.008) and IV (OR = 1.63 95%CI 1.03–2.59, p = 0.038). Major organ resections had the greatest odds of VTE when adjusted for other risk factors including length of hospital stay. Post-discharge VTE accounted for 64.8% (636/981) of all recorded VTE. In-hospital VTE (165.4/1000 patient-years) was recorded more frequently than post-discharge VTE (16.2/1000 patient-years). Both in-hospital (OR = 2.07 95%CI 1.51–2.85, p<0.001) and post-discharge (OR = 4.03 95%CI 2.95–5.51, p<0.001) VTE independently predicted 90-day mortality. In patients who died and VTE was recorded on HES or CPRD (n = 56), VTE was one of the causes of death in 37.5% (21/56) of cases. Conclusions A large proportion of postoperative VTE was detected in primary care. Evaluation of linked databases was a useful way of measuring postoperative VTE at population level. These resources identified a significant association between post-discharge VTE and mortality in general surgery. PMID:26713434
Risk of Post-Discharge Venous Thromboembolism and Associated Mortality in General Surgery: A Population-Based Cohort Study Using Linked Hospital and Primary Care Data in England.

PubMed

Bouras, George; Burns, Elaine Marie; Howell, Ann-Marie; Bottle, Alex; Athanasiou, Thanos; Darzi, Ara

2015-01-01

Trends towards day case surgery and enhanced recovery mean that postoperative venous thromboembolism (VTE) may increasingly arise after hospital discharge. However, hospital data alone are unable to capture adverse events that occur outside of the hospital setting. The National Institute for Health and Care Excellence has suggested the use of primary care data to quantify hospital care-related VTE. Data in surgical patients using these resources is lacking. The aim of this study was to measure VTE risk and associated mortality in general surgery using linked primary care and hospital databases, to improve our understanding of harm from VTE that arises beyond hospital stay. This was a longitudinal cohort study using nationally linked primary care (Clinical Practice Research Datalink, CPRD), hospital administrative (Hospital Episodes Statistics, HES), population statistics (Office of National Statistics, ONS) and National Cancer Intelligence Network databases. Routinely collected information was used to quantify 90-day in-hospital VTE, 90-day post-discharge VTE and 90-day mortality in adults undergoing one of twelve general surgical procedures between 1st April 1997 and 31st March 2012. The earliest postoperative recording of deep vein thrombosis or pulmonary embolism in CPRD, HES and ONS was counted in each patient. Covariates from multiple datasets were combined to derive detailed prediction models for VTE and mortality. Limitation included the capture of VTE presenting to healthcare only and the lack of information on adherence to pharmacological thromboprophylaxis as there was no data linkage to hospital pharmacy records. There were 981 VTE events captured within 90 days of surgery in 168005 procedures (23.7/1000 patient-years). Overall, primary care data increased the detection of postoperative VTE by a factor of 1.38 (981/710) when compared with using HES and ONS only. Total VTE rates ranged between 3.2/1000 patient-years in haemorrhoidectomy to 118.3/1000 patient-years in esophagogastric resection. Predictors of VTE included emergency surgery (OR = 1.91 95%CI 1.60-2.28, p<0.001), age (OR = 1.02 95%CI 1.02-1.03, p<0.001), body mass index (OR = 1.03 95%CI 1.01-1.04, p<0.001), previous VTE (OR = 8.07 95%CI 6.61-9.83, p<0.001), length of stay (OR = 1.00 95%CI 1.00-1.00, p = 0.007) and cancer stages II (OR = 1.38 95%CI 1.03-1.87, p = 0.033), III (OR = 1.50 95%CI 1.11-2.01, p = 0.008) and IV (OR = 1.63 95%CI 1.03-2.59, p = 0.038). Major organ resections had the greatest odds of VTE when adjusted for other risk factors including length of hospital stay. Post-discharge VTE accounted for 64.8% (636/981) of all recorded VTE. In-hospital VTE (165.4/1000 patient-years) was recorded more frequently than post-discharge VTE (16.2/1000 patient-years). Both in-hospital (OR = 2.07 95%CI 1.51-2.85, p<0.001) and post-discharge (OR = 4.03 95%CI 2.95-5.51, p<0.001) VTE independently predicted 90-day mortality. In patients who died and VTE was recorded on HES or CPRD (n = 56), VTE was one of the causes of death in 37.5% (21/56) of cases. A large proportion of postoperative VTE was detected in primary care. Evaluation of linked databases was a useful way of measuring postoperative VTE at population level. These resources identified a significant association between post-discharge VTE and mortality in general surgery.
Epidemiology of paediatric presentations with musculoskeletal problems in primary care.

PubMed

Tan, Albert; Strauss, Victoria Y; Protheroe, Joanne; Dunn, Kate M

2018-02-06

Musculoskeletal disease is a common cause of morbidity, but there is a paucity of musculoskeletal research focusing on paediatric populations, particularly in primary care settings. In particular, there is limited information on population consultation frequency in paediatric populations, and frequency varies by age and sex. Few studies have examined paediatric musculoskeletal consultation frequency for different body regions. The objective was to determine the annual consultation prevalence of regional musculoskeletal problems in children in primary care. Musculoskeletal codes within the Read morbidity Code system were identified and grouped into body regions. Consultations for children aged three to seventeen in 2006 containing these codes were extracted from recorded consultations at twelve general practices contributing to a general practice consultation database (CiPCA). Annual consultation prevalence per 10,000 registered persons for the year 2006 was determined, stratified by age and sex, for problems in individual body regions. Over 8 % (8.27%, 95% CI 7.86 to 8.68%) of the 16,862 children consulted with a musculoskeletal problem during 2006. Annual consultation prevalence for any musculoskeletal problem was significantly higher in males than females (male: female prevalence ratio 1.18, 95% CI 1.06 to 1.31). Annual consultation prevalence increased with age and the most common body regions consulted for were the foot, knee and back all of which had over 100 consultations (109, 104 and 101 respectively) per 10,000 persons per year. This study provides new and detailed information on patterns of paediatric musculoskeletal consultations in primary care. Musculoskeletal problems in children are varied and form a significant part of the paediatric primary care workload. The findings of this study may be used as a resource for planning future studies.
Design and rationale for Home Blood Pressure Telemonitoring and Case Management to Control Hypertension (HyperLink): a cluster randomized trial.

PubMed

Margolis, Karen L; Kerby, Tessa J; Asche, Stephen E; Bergdall, Anna R; Maciosek, Michael V; O'Connor, Patrick J; Sperl-Hillen, JoAnn M

2012-07-01

Patients with high blood pressure (BP) visit a physician an average of 4 times or more per year in the U.S., yet BP is controlled in fewer than half. Practical, robust and sustainable models are needed to improve BP in patients with uncontrolled hypertension. The Home Blood Pressure Telemonitoring and Case Management to Control Hypertension study (HyperLink) is a cluster-randomized trial designed to determine whether an intervention that combines home BP telemonitoring with pharmacist case management improves BP control compared to usual care at 6 and 12 months in patients with uncontrolled hypertension. Secondary outcomes are maintenance of BP control at 18 months, patient satisfaction with their health care, and costs of care. HyperLink enrolled 450 hypertensive patients with uncontrolled BP from 16 primary care clinics. Eight clinics were randomized to provide usual care (UC) to their patients (n=222) and 8 were randomized to provide the telemonitoring intervention (TI) (n=228). TI patients received home BP telemonitors that internally store and electronically transmit BP data to a secure database. Pharmacist case managers adjust antihypertensive therapy based on the home BP data under a collaborative practice agreement with the clinics' primary care teams. The length of the intervention is 12 months, with follow-up to 18 months to determine the durability of the intervention. We will test in a real primary care setting whether combining BP telemonitoring and pharmacist case management can achieve and maintain high rates of BP control compared to usual care. Copyright © 2012 Elsevier Inc. All rights reserved.
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.
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.
Impact of chronic kidney disease management in primary care.

PubMed

Meran, S; Don, K; Shah, N; Donovan, K; Riley, S; Phillips, A O

2011-01-01

The introduction of eGFR reporting and publication of national CKD guidelines has led to major challenges in primary and secondary care, leading to an increase in the number of referrals to nephrology clinics. We have shown that introduction of a renal patient care pathway reduces nephrology referrals and enables managed discharges of CKD patients to primary care. The aim of this article is to examine the outcome of patients discharged to primary care to find out if there is an associated risk with increased discharge supported by the patient pathway. The study was carried out within a single NHS Trust covering a population of 560,000. All patients discharged from the trust's renal outpatient clinic between June 2007 and July 2008 were identified. Patient notes and the local laboratory database systems were used to determine the source and timing of tests. A total of 31 new referrals and 57 regular follow-ups were discharged during this period. The median age of discharge was 67.5 years. Most subjects (60%) had CKD stage 3 at the time of discharge. A total of 23% of discharges were categorized as CKD stages 1, 2 or normal and 17% of patients had CKD stage 4. Overall, 93% had stable eGFRs prior to discharge, 77.5% of patients had blood pressure within threshold (140/90 according to UK CKD guidelines) and 97.7% of patients had haemoglobins >10 g/dl. Post-discharge 83% of patients had eGFRs recorded by their general practitioner and 92.6% of these were measured within appropriate time frames as per CKD guidelines. The majority of patients (82%) had either improved or stable eGFR post-discharge and only three patients had a significant decline in their eGFR. These data indicate that selected CKD patients can be appropriately discharged from secondary care and adequately monitored in primary care. Furthermore, we have shown that this was a safe practice for patients.
Healthcare Costs of Rotavirus and Other Types of Gastroenteritis in Children in Norway.

PubMed

Shin, Minkyung; Salamanca, Beatriz Valcarcel; Kristiansen, Ivar S; Flem, Elmira

2016-04-01

Norway has initiated a publicly funded rotavirus immunization program for all age-eligible children in 2014. We aimed to estimate the healthcare costs of rotavirus gastroenteritis in children younger than 5 years old. We identified all gastroenteritis cases in children younger than 5 years old treated during 2009-2013 through the national claims database for primary care and the national hospital registry. We estimated direct medical costs of rotavirus-associated primary care consultations and hospital encounters (inpatient admission, outpatient visit and ambulatory care). We performed a range of one-way sensitivity analyses to explore uncertainty in the cost estimates. Before vaccine introduction, the mean healthcare cost of rotavirus gastroenteritis in children younger than 5 years old was €4,440,337 per year. Among rotavirus-associated costs, 92% were hospital costs and the remaining 8% were primary care costs. The mean annual cost of rotavirus-associated hospital encounters was €4,083,691, of which 95% were costs of inpatient hospital admissions. The average healthcare cost of medically attended gastroenteritis in children younger than 5 years old was approximately €8 million per year, of which rotavirus-related costs represented 56%. Healthcare costs of rotavirus gastroenteritis in Norway are substantial. The cost-effectiveness of ongoing rotavirus immunization program should be reassessed.
Psychiatry's Role in the Management of Human Trafficking Victims: An Integrated Care Approach.

PubMed

Gordon, Mollie; Salami, Temilola; Coverdale, John; Nguyen, Phuong T

2018-03-01

Human trafficking is an outrageous human rights violation with potentially devastating consequences to individuals and the public health. Victims are often underrecognized and there are few guidelines for how best to identify, care for, and safely reintegrate victims back into the community. The purpose of this paper is to propose a multifaceted, interdisciplinary, and interprofessional guideline for providing care and services to human trafficking victims. Databases such as PubMed and PsycINFO were searched for papers outlining human trafficking programs with a primary psychiatric focus. No integrated care models that provide decisional guidelines at different points of intervention for human trafficking patients and that highlight the important role of psychiatric consultation were found. Psychiatrists and psychologists are pivotal to an integrated care approach in health care settings. The provision of such a comprehensive and integrated model of care should facilitate the identification of victims, promote their recovery, and reduce the possibility of retraumatization.
Mental health care: how can Family Health teams integrate it into Primary Healthcare?

PubMed

Gryschek, Guilherme; Pinto, Adriana Avanzi Marques

2015-10-01

Mental health is one of the responsibilities of Brazil's Family Health system. This review of literature sought to understand what position Mental Health occupies in the practice of the Family Health Strategy. A search was made of the scientific literature in the database of the Virtual Health Library (Biblioteca Virtual de Saúde), for the keywords: 'Mental Health'; 'Family Health'; 'Primary Healthcare'. The criteria for inclusion were: Brazilian studies from 2009 through 2012 that contributed to understanding of the following question: "How to insert Mental health care into the routine of the Family Health Strategy?" A total of 11 articles were found, which identified difficulties and strategies of the professionals in Primary Healthcare in relation to mental health. Referral, and medicalization, were common practices. Matrix Support is the strategy of training and skill acquisition for teams that enables new approaches in mental health in the context of Primary healthcare. It is necessary for Management of the Health System to take an active role in the construction of healthcare networks in mental health.
The network of Shanghai Stroke Service System (4S): A public health-care web-based database using automatic extraction of electronic medical records.

PubMed

Dong, Yi; Fang, Kun; Wang, Xin; Chen, Shengdi; Liu, Xueyuan; Zhao, Yuwu; Guan, Yangtai; Cai, Dingfang; Li, Gang; Liu, Jianmin; Liu, Jianren; Zhuang, Jianhua; Wang, Panshi; Chen, Xin; Shen, Haipeng; Wang, David Z; Xian, Ying; Feng, Wuwei; Campbell, Bruce Cv; Parsons, Mark; Dong, Qiang

2018-07-01

Background Several stroke outcome and quality control projects have demonstrated the success in stroke care quality improvement through structured process. However, Chinese health-care systems are challenged with its overwhelming numbers of patients, limited resources, and large regional disparities. Aim To improve quality of stroke care to address regional disparities through process improvement. Method and design The Shanghai Stroke Service System (4S) is established as a regional network for stroke care quality improvement in the Shanghai metropolitan area. The 4S registry uses a web-based database that automatically extracts data from structured electronic medical records. Site-specific education and training program will be designed and administrated according to their baseline characteristics. Both acute reperfusion therapies including thrombectomy and thrombolysis in the acute phase and subsequent care were measured and monitored with feedback. Primary outcome is to evaluate the differences in quality metrics between baseline characteristics (including rate of thrombolysis in acute stroke and key performance indicators in secondary prevention) and post-intervention. Conclusions The 4S system is a regional stroke network that monitors the ongoing stroke care quality in Shanghai. This project will provide the opportunity to evaluate the spectrum of acute stroke care and design quality improvement processes for better stroke care. A regional stroke network model for quality improvement will be explored and might be expanded to other large cities in China. Clinical Trial Registration-URL http://www.clinicaltrials.gov . Unique identifier: NCT02735226.
Advances and challenges in oral health after a decade of the "Smiling Brazil" Program.

PubMed

Scherer, Charleni Inês; Scherer, Magda Duarte dos Anjos

2015-01-01

To analyze oral health work changes in primary health care after Brazil's National Oral Health Policy Guidelines were released. A literature review was conducted on Medline, LILACS, Embase, SciELO, Biblioteca Virtual em Saúde, and The Cochrane Library databases, from 2000 to 2013, on elements to analyze work changes. The descriptors used included: primary health care, family health care, work, health care policy, oral health care services, dentistry, oral health, and Brazil. Thirty-two studies were selected and analyzed, with a predominance of qualitative studies from the Northeast region with workers, especially dentists, focusing on completeness and quality of care. Observed advances focused on educational and permanent education actions; on welcoming, bonding, and accountability. The main challenges were related to completeness; extension and improvement of care; integrated teamwork; working conditions; planning, monitoring, and evaluation of actions; stimulating people's participation and social control; and intersectorial actions. Despite the new regulatory environment, there are very few changes in oral health work. Professionals tend to reproduce the dominant biomedical model. Continuing efforts will be required in work management, training, and permanent education fields. Among the possibilities are the increased engagement of managers and professionals in a process to understand work dynamics and training in the perspective of building significant changes for local realities.
[Potentially inappropriate prescribing in older Spanish population according to STOPP/START criteria (STARTREC study)].

PubMed

Cruz-Esteve, Inés; Marsal-Mora, Josep Ramón; Galindo-Ortego, Gisela; Galván-Santiago, Leonardo; Serrano-Godoy, Marcos; Ribes-Murillo, Esther; Real-Gatius, Jordi

2017-03-01

Rational prescribing in older people is a priority for health care organizations. The STOPP/START screening tool has been developed to identify potentially inappropriate prescribing (PIP) in individuals. In a primary care setting, STOPP/START can estimate PIP prevalence and related factors at population level. The aim of this study is to measure the prevalence rates of PPI in elderly population using clinical and prescription claim databases. Cross-sectional population study. Primary Care, Lleida Health Region, Spain. 45.408 patients 70 years old and over, attended in the primary health care centers at least once the last year. 43 STOPP and 12 START criteria are applied to their 2012 clinical and prescription records. Logistic regression models are adjusted to determine PIP association with several factors. 45,408 patients are included. The mean age is 79.7 years, 58% being female. The overall prevalence of PPI is 58.1%. According to STOPP, the most common drugs identified are benzodiazepines, non-steroidal anti-inflammatory drugs and proton pump inhibitors; according to START, osteoporosis treatments, antiplatelet agents, statins, metformin and beta blockers. PIP increases with age and polypharmacy and it is higher in long-term care facilities residents and patients receiving home health care. In our Health Region, at least 50% of the population aged 70 or older has one or more PIP, according to STOPP/START criteria. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.
Counselling for depression in primary care.

PubMed

Rowland, N; Bower, P; Mellor, C; Heywood, P; Godfrey, C

2001-01-01

There is wide clinician and patient support for counselling in primary care, particularly in the UK. This review examines the effectiveness and cost effectiveness of counselling for psychological and psychosocial problems in the primary care setting. To assess the effects of counselling in primary care by reviewing cost and outcome data for patients with psychological and psychosocial problems considered suitable for counselling. The 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. Contact was made with subject experts and CCDAN members. Randomised and controlled patient preference trials comparing counselling in primary care with usual general practitioner care for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of April 1998 were included in the review. Trials were independently assessed by at least two reviewers for appropriateness of inclusion and methdological quality. Four trials, involving 678 participants, of whom 487 were followed up, were included. Data for psychological symptom levels (four trials) were pooled statistically. Patients receiving counselling had significantly better psychological symptom levels post intervention than patients receiving usual general practitioner care (standardised mean difference -0.30, 95% CI, (-0.49 to - 0.11). The effect remained statistically significant when the results from studies with less rigorous methodology were excluded in a sensitivity analysis. Patients who received counselling tended to be more satisfied with their treatment (three trials). Health service utilisation data were reported in all trials reviewed, but only one trial undertook a cost analysis. No clear cost advantage was associated with either counselling or usual general practice care. Patients who received counselling were more likely to have improved psychological symptom levels than those who did not receive counselling. Levels of satisfaction with counselling were high. There is limited information about the cost effectiveness of counselling, with one study reporting no clear cost advantage with either counselling or general practice care. The four trials included in this review were all pragmatic trials of counselling in primary care in the UK, which reflect the reality of clinical provision in this context. There were methdological weaknesses identified in the studies, which should be taken into account when considering the results. The evidence base will be extended by trials of counselling which are nearing completion.
What do primary care practitioners want to know? A content analysis of questions asked at the point of care.

PubMed

Bjerre, Lise M; Paterson, Nicholas R; McGowan, Jessie; Hogg, William; Campbell, Craig M; Viner, Gary; Archibald, Douglas

2013-01-01

Assessing physician needs to develop continuing medical education (CME) activities is an integral part of CME curriculum development. The purpose of the present study was to demonstrate the feasibility of identifying areas of perceived greatest needs for continuing medical education (CME) by using questions collected electronically at the point of care. This study is a secondary analysis of the "Just-in-Time" (JIT) information librarian consultation service database of questions using quantitative content analysis methods. The original JIT project demonstrated the feasibility of a real-time librarian service for answering questions asked by primary care clinicians at the point of care using a Web-based platform or handheld device. Data were collected from 88 primary care practitioners in Ontario, Canada, from October 2005 to April 2006. Questions were answered in less than 15 minutes, enabling clinicians to use the answer during patient encounters. Description of type and frequency of questions asked, including the organ system on which the questions focused, was produced using 2 classification systems, the "taxonomy of generic clinical questions" (TGCQ), and the International Classification for Primary Care version 2 (ICPC-2). Of the original 1889 questions, 1871 (99.0%) were suitable for analysis. A total of 970 (52%) of questions related to therapy; of these, 671 (69.2%) addressed questions about drug therapy, representing 36% of all questions. Questions related to diagnosis (24.8%) and epidemiology (13.5%) were also common. Organ systems questions concerning musculoskeletal, endocrine, skin, cardiac, and digestive systems were asked more than other categories. Questions collected at the point of care provide a valuable and unique source of information on the true learning needs of practicing clinicians. The TGCQ classification allowed us to show that a majority of questions had to do with treatment, particularly drug treatment, whereas the use of the ICPC-2 classification illustrated the great variety of questions asked about the diverse conditions encountered in primary care. It is feasible to use electronically collected questions asked by primary care clinicians in clinical practice to categorize self-identified knowledge and practice needs. This could be used to inform the development of future learning activities. Copyright © 2013 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.
Barriers that practitioners face when initiating insulin therapy in general practice settings and how they can be overcome

PubMed Central

Bin rsheed, Abdulaziz; Chenoweth, Ian

2017-01-01

AIM To explore primary care physicians’ perspectives on possible barriers to the use of insulin. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eight electronic databases were searched (between January 1, 1994 and August 31, 2014) for relevant studies. A search for grey literature and a review of the references in the retrieved studies were also conducted. Studies that focused on healthcare providers’ perspectives on possible barriers to insulin initiation with type 2 diabetic patients were included, as well as articles suggesting solutions for these barriers. Review articles and studies that only considered patients’ perspectives were excluded. RESULTS A total of 19 studies met the inclusion criteria and were therefore included in this study: 10 of these studies used qualitative methods, 8 used quantitative methods and 1 used mixed methods. Studies included a range of different health care settings. The findings are reported under four broad categories: The perceptions of primary care physicians about the barriers to initiate insulin therapy for type 2 diabetes patients, how primary care physicians assess patients prior to initiating insulin, professional roles and possible solutions to overcome these barriers. The barriers described were many and covered doctor, patient, system and technological aspects. Interventions that focused on doctor training and support, or IT-based decision support were few, and did not result in significant improvement. CONCLUSION Primary care physicians’ known delay in insulin initiation is multifactorial. Published reports of attempts to find solutions for these barriers were limited in number. PMID:28138362

Current status of palliative care services in Indonesia: a literature review.

PubMed

Rochmawati, Erna; Wiechula, Rick; Cameron, Kate

2016-06-01

To review healthcare literature in relation to the provision of palliative care in Indonesia and to identify factors that may impact on palliative care development. People living with life-limiting illness benefit from access to palliative care services to optimize quality of life. Palliative care services are being expanded in developing countries but in Indonesia such services are in their infancy with many patients with life-limiting illnesses having access to appropriate health care compromised. Relevant healthcare databases including CINAHL, PubMed, Science Direct and Scopus were searched using the combinations of search terms: palliative care, terminal care, end-of-life care, Indonesia and nursing. A search of grey literature including Internet sites was also carried out. Nine articles were included in the review. Facilitating factors supporting the provision of palliative care included: a culture of strong familial support, government policy support, volunteering and support from regional organizations. Identified barriers to palliative care provision were a limited understanding of palliative care among healthcare professionals, the challenging geography of Indonesia and limited access to opioid medications. There are facilitators and barriers that currently impact on the development of palliative care in Indonesia. Strategies that can be implemented to improve palliative care include training of nurses and doctors in the primary care sector, integrating palliative care in undergraduate medical and nursing curriculum and educating family and community about basic care. Nurses and doctors who work in primary care can potentially play a role in supporting and educating family members providing direct care to patients with palliative needs. © 2016 International Council of Nurses.
Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review.

PubMed

Kornhaber, Rachel Anne; de Jong, A E E; McLean, L

2015-12-01

Qualitative methods are progressively being implemented by researchers for exploration within healthcare. However, there has been a longstanding and wide-ranging debate concerning the relative merits of qualitative research within the health care literature. This integrative review aimed to exam the contribution of qualitative research in burns care and subsequent rehabilitation. Studies were identified using an electronic search strategy using the databases PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Excerpta Medica database (EMBASE) and Scopus of peer reviewed primary research in English between 2009 to April 2014 using Whittemore and Knaﬂ's integrative review method as a guide for analysis. From the 298 papers identified, 26 research papers met the inclusion criteria. Across all studies there was an average of 22 participants involved in each study with a range of 6-53 participants conducted across 12 nations that focussed on burns prevention, paediatric burns, appropriate acquisition and delivery of burns care, pain and psychosocial implications of burns trauma. Careful and rigorous application of qualitative methodologies promotes and enriches the development of burns knowledge. In particular, the key elements in qualitative methodological process and its publication are critical in disseminating credible and methodologically sound qualitative research. Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.
Implementation of behavioral health interventions in real world scenarios: Managing complex change.

PubMed

Clark, Khaya D; Miller, Benjamin F; Green, Larry A; de Gruy, Frank V; Davis, Melinda; Cohen, Deborah J

2017-03-01

A practice embarks on a radical reformulation of how care is designed and delivered when it decides to integrate medical and behavioral health care for its patients and success depends on managing complex change in a complex system. We examined the ways change is managed when integrating behavioral health and medical care. Observational cross-case comparative study of 19 primary care and community mental health practices. We collected mixed methods data through practice surveys, observation, and semistructured interviews. We analyzed data using a data-driven, emergent approach. The change management strategies that leadership employed to manage the changes of integrating behavioral health and medical care included: (a) advocating for a mission and vision focused on integrated care; (b) fostering collaboration, with a focus on population care and a team-based approaches; (c) attending to learning, which includes viewing the change process as continuous, and creating a culture that promoted reflection and continual improvement; (d) using data to manage change, and (e) developing approaches to finance integration. This paper reports the change management strategies employed by practice leaders making changes to integrate care, as observed by independent investigators. We offer an empirically based set of actionable recommendations that are relevant to a range of leaders (policymakers, medical directors) and practice members who wish to effectively manage the complex changes associated with integrated primary care. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
Interprofessional education in primary health care for entry level students--A systematic literature review.

PubMed

Kent, Fiona; Keating, Jennifer L

2015-12-01

This systematic review investigated student learning and patient outcomes associated with interprofessional education in outpatient, primary care clinics. Medline, Cinahl and Embase databases were searched to March 2014. A mixed method evaluation framework was applied to investigate the participants, interventions and effects on student learning and patient outcomes. 26 studies met the inclusion criteria; 13 were quantitative, predominately pre-post-survey design, 6 qualitative and 7 mixed methods design. Studies most commonly investigated student volunteers from medicine, nursing and allied health working in interprofessional clinics that were established to address gaps in community health care. Students appeared to learn teamwork skills and increase their knowledge of the roles of other disciplines. We found no convincing evidence that participation results in changes in attitudes towards other disciplines compared to single discipline education. We also found insufficient evidence to estimate the effectiveness of patient care delivered by interprofessional student teams in this setting compared to single discipline or no care. Given the logistical challenges associated with coordinating clinic attendance for interprofessional teams, high quality studies are needed to assess the effects of clinics on student learning and patient health outcomes. Copyright © 2015 Elsevier Ltd. All rights reserved.
Imbalance between Goals and Organizational Structure in Primary Health Care in Iran- a Systematic Review.

PubMed

Zanganeh Baygi, Mehdi; Seyedin, Hesam

2013-07-01

In recent years, the main focus of health sector reforms in Iran is the family physician and referral system plan. Fundamental changes in the goals and strategies, has increased the necessity of the need to reform the organizational structure. This study tries to review and summarize all cases about the organizational structure of Iran and its challenges in primary health care system. This study was a systematic review of published and grey literature. We searched the relevant databases, bibliography of related papers, and laws, using appropriate search strategies and key words. The CASP tool was used by two experts to evaluate the quality of retrieved papers and inconsistencies were resolved by discussion. After removal of duplicate citations, a total of 52 titles were identified through database searching, among which 30 met the inclusion criteria. Considering the research quality criteria, 14 papers were recognized qualified, which were categorized into two groups of: articles and policies. The results showed ineffectiveness of the current organizational structure at different level. The majority of the papers recommend performing reforms in the system because of changes in goals and strategies. Also, some suggest an appropriate information system to be designed in the current structures. Centralization and delegation process are the main discussions for the studies. Because of fundamental changes in goals and strategies, reforms in the organizational structure of primary health system in Iran especially in peripheral levels are highly recommended.
Health consequences of adverse childhood experiences: a systematic review.

PubMed

Kalmakis, Karen A; Chandler, Genevieve E

2015-08-01

Adverse childhood experiences (ACEs) have been associated with negative health outcomes, but the evidence has had limited application in primary care practice. The purpose of this study was to systematically review the research on associations between ACEs and adult health outcomes to inform nurse practitioners (NPs) in primary care practice. The databases PubMed, CINAHL, PsycINFO, and Social Abstracts were searched for articles published in English between 2008 and 2013 using the search term "adverse childhood experiences." Forty-two research articles were included in the synthesis. The evidence was synthesized and is reported following the preferred reporting items for systematic reviews and meta-analysis procedure (PRISMA). ACEs have been associated with health consequences including physical and psychological conditions, risk behaviors, developmental disruption, and increased healthcare utilization. Generalization of the results is limited by a majority of studies (41/42) measuring childhood adversity using self-report measures. NPs are encouraged to incorporate assessment of patients' childhood history in routine primary care and to consider the evidence that supports a relationship between ACEs and health. Although difficult, talking about patient's childhood experiences may positively influence health outcomes. ©2015 American Association of Nurse Practitioners.
Supplementing electronic health records through sample collection and patient diaries: A study set within a primary care research database.

PubMed

Joseph, Rebecca M; Soames, Jamie; Wright, Mark; Sultana, Kirin; van Staa, Tjeerd P; Dixon, William G

2018-02-01

To describe a novel observational study that supplemented primary care electronic health record (EHR) data with sample collection and patient diaries. The study was set in primary care in England. A list of 3974 potentially eligible patients was compiled using data from the Clinical Practice Research Datalink. Interested general practices opted into the study then confirmed patient suitability and sent out postal invitations. Participants completed a drug-use diary and provided saliva samples to the research team to combine with EHR data. Of 252 practices contacted to participate, 66 (26%) mailed invitations to patients. Of the 3974 potentially eligible patients, 859 (22%) were at participating practices, and 526 (13%) were sent invitations. Of those invited, 117 (22%) consented to participate of whom 86 (74%) completed the study. We have confirmed the feasibility of supplementing EHR with data collected directly from patients. Although the present study successfully collected essential data from patients, it also underlined the requirement for improved engagement with both patients and general practitioners to support similar studies. © 2017 The Authors. Pharmacoepidemiology & Drug Safety published by John Wiley & Sons Ltd.
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 quality of Australian Indigenous primary health care research focusing on social and emotional wellbeing: a systematic review.

PubMed

Farnbach, Sara; Eades, Anne-Maree; Fernando, Jamie K; Gwynn, Josephine D; Glozier, Nick; Hackett, Maree L

2017-10-11

Objectives and importance of the study: Primary health care research focused on Aboriginal and Torres Strait Islander (Indigenous) people is needed to ensure that key frontline services provide evidence based and culturally appropriate care. We systematically reviewed the published primary health care literature to identify research designs, processes and outcomes, and assess the scientific quality of research focused on social and emotional wellbeing. This will inform future research to improve evidence based, culturally appropriate primary health care. Systematic review in accordance with PRISMA and MOOSE guidelines. Four databases and one Indigenous-specific project website were searched for qualitative, quantitative and mixed-method published research. Studies that were conducted in primary health care services and focused on the social and emotional wellbeing of Indigenous people were included. Scientific quality was assessed using risk-of-bias assessment tools that were modified to meet our aims. We assessed community acceptance by identifying the involvement of community governance structures and representation during research development, conduct and reporting. Data were extracted using standard forms developed for this review. We included 32 articles, which reported on 25 studies. Qualitative and mixed methods were used in 18 studies. Twelve articles were judged as high or unclear risk of bias, four as moderate and five as low risk of bias. Another four studies were not able to be assessed as they did not align with the risk-of-bias tools. Of the five articles judged as low risk of bias, two also had high community acceptance and both of these were qualitative. One used a phenomenological approach and the other combined participatory action research with a social-ecological perspective and incorporated 'two-way learning' principles. Of the 16 studies where a primary outcome was identified, eight aimed to identify perceptions or experiences. The remaining studies assessed resources, or evaluated services, interventions, programs or policies. We were unable to identify primary outcomes in eight studies. Conducting Indigenous-focused primary health care research that is scientifically robust, culturally appropriate and produces community-level outcomes is challenging. We suggest that research teams use participatory, culturally sensitive approaches and collaborate closely to plan and implement high-quality research that incorporates local perspectives. Research should result in beneficial outcomes for the communities involved.
A national surveillance project on chronic kidney disease management in Canadian primary care: a study protocol.

PubMed

Bello, Aminu K; Ronksley, Paul E; Tangri, Navdeep; Singer, Alexander; Grill, Allan; Nitsch, Dorothea; Queenan, John A; Lindeman, Cliff; Soos, Boglarka; Freiheit, Elizabeth; Tuot, Delphine; Mangin, Dee; Drummond, Neil

2017-08-04

Effective chronic disease care is dependent on well-organised quality improvement (QI) strategies that monitor processes of care and outcomes for optimal care delivery. Although healthcare is provincially/territorially structured in Canada, there are national networks such as the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) as important facilitators for national QI-based studies to improve chronic disease care. The goal of our study is to improve the understanding of how patients with chronic kidney disease (CKD) are managed in primary care and the variation across practices and provinces and territories to drive improvements in care delivery. The CPCSSN database contains anonymised health information from the electronic medical records for patients of participating primary care practices (PCPs) across Canada (n=1200). The dataset includes information on patient sociodemographics, medications, laboratory results and comorbidities. Leveraging validated algorithms, case definitions and guidelines will help define CKD and the related processes of care, and these enable us to: (1) determine prevalent CKD burden; (2) ascertain the current practice pattern on risk identification and management of CKD and (3) study variation in care indicators (eg, achievement of blood pressure and proteinuria targets) and referral pattern for specialist kidney care. The process of care outcomes will be stratified across patients' demographics as well as provider and regional (provincial/territorial) characteristics. The prevalence of CKD stages 3-5 will be presented as age-sex standardised prevalence estimates stratified by province and as weighted averages for population rates with 95% CIs using census data. For each PCP, age-sex standardised prevalence will be calculated and compared with expected standardised prevalence estimates. The process-based outcomes will be defined using established methods. The CPCSSN is committed to high ethical standards when dealing with individual data collected, and this work is reviewed and approved by the Network Scientific Committee. The results will be published in peer-reviewed journals and presented at relevant national and international scientific meetings. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Out-of-hours primary care use at the end of life: a descriptive study

PubMed Central

Fisher, Rebecca FR; Lasserson, Daniel; Hayward, Gail

2016-01-01

Background Out-of-hours (OOH) primary care services are integral to the care of patients at end of life. Little is known about the OOH service usage of patients with palliative care needs. Aim To describe patterns of usage of patients presenting to an OOH service and coded as ‘palliative’. Design and setting A descriptive study of data from the Oxfordshire OOH service. Method A database of all patient contacts with the Oxfordshire OOH service from a 4-year period (June 2010–August 2014) was used to extract demographic and service usage data for all contacts to which clinicians had applied a ‘palliative’ code. Observed differences in demographic features between palliative and non-palliative contacts were tested using logistic regression. Results Out of a total of 496 931 contacts, there were 6045 contacts coded palliative; those ‘palliative’ contacts provided care to 3760 patients. Patients contacting the OOH service with palliative care needs did so predominantly during weekend daytime periods, and over a third had more than one contact. Patients were predictably older than the average population, but contacts coded as ‘palliative’ were relatively less deprived than contacts to the OOH service for all causes, even after adjusting for age and sex. Conclusion The current ‘one-size-fits-most’ model of OOH primary care may not allow for the specific needs of patients at the end of life. Wider analysis of palliative patient flow through urgent care services is needed to identify whether healthcare access at the end of life is inequitable, as well as the capacity requirements of a community-based service that can provide high-quality end-of-life care. PMID:27381487
Comparison of costs and discharge outcomes for patients hospitalized for ischemic or hemorrhagic stroke with or without atrial fibrillation in the United States.

PubMed

Pan, Xianying; Simon, Teresa A; Hamilton, Melissa; Kuznik, Andreas

2015-05-01

This retrospective analysis investigated the impact of baseline clinical characteristics, including atrial fibrillation (AF), on hospital discharge status (to home or continuing care), mortality, length of hospital stay, and treatment costs in patients hospitalized for stroke. The analysis included adult patients hospitalized with a primary diagnosis of ischemic or hemorrhagic stroke between January 2006 and June 2011 from the premier alliance database, a large nationally representative database of inpatient health records. Patients included in the analysis were categorized as with or without AF, based on the presence or absence of a secondary listed diagnosis of AF. Irrespective of stroke type (ischemic or hemorrhagic), AF was associated with an increased risk of mortality during the index hospitalization event, as well as a higher probability of discharge to a continuing care facility, longer duration of stay, and higher treatment costs. In patients hospitalized for a stroke event, AF appears to be an independent risk factor of in-hospital mortality, discharge to continuing care, length of hospital stay, and increased treatment costs.
Linking and integrating computers for maternity care.

PubMed

Lumb, M; Fawdry, R

1990-12-01

Functionally separate computer systems have been developed for many different areas relevant to maternity care, e.g. maternity data collection, pathology and imaging reports, staff rostering, personnel, accounting, audit, primary care etc. Using land lines, modems and network gateways, many such quite distinct computer programs or databases can be made accessible from a single terminal. If computer systems are to attain their full potential for the improvement of the maternity care, there will be a need not only for terminal emulation but also for more complex integration. Major obstacles must be overcome before such integration is widely achieved. Technical and conceptual progress towards overcoming these problems is discussed, with particular reference to the OSI (open systems interconnection) initiative, to the Read clinical classification and to the MUMMIES CBS (Common Basic Specification) Maternity Care Project. The issue of confidentiality is also briefly explored.
Understanding adherence to therapeutic guidelines: a multilevel analysis of statin prescription in the Skaraborg Primary Care Database.

PubMed

Hjerpe, Per; Ohlsson, Henrik; Lindblad, Ulf; Boström, Kristina Bengtsson; Merlo, Juan

2011-04-01

In Skaraborg, Sweden, the economic responsibility for tax-financed prescription drug costs was transferred from the regional administrative level to the local level (health care centre; HCC) in 2003. The aim of this study was to investigate the impact of this decentralization of economic responsibility on adherence to guidelines for prescribing lipid-lowering drugs. Data from all 24 public HCCs in Skaraborg on prescriptions for lipid-lowering drugs during 2003 and 2005 were extracted from the Skaraborg Primary Care Database (SPCD). Multilevel regression analysis (MLRA) was used to disentangle the variances at different levels of data (patient, physician, HCC). The outcome variable on the patient level was the prescription of the recommended statin (yes/no). Sex and age of the patients and sex, age and occupational status of the physician were included as fixed effects. The variance was expressed as the median odds ratio (MOR). The prevalence of adherence to guidelines for the prescription of statins increased from 77% in 2003 to 84% in 2005. The MLRA showed that in 2003 the variance was equally distributed between the HCC and physician levels (MOR(HCC2003)=1.89 vs. MOR(PHYSICIAN2003)=1.88). The variance between physicians and between HCCs decreased considerably between 2003 and 2005. The inclusion of individual and physician characteristics did not explain any of the remaining variance. The decentralized budget appears to have increased adherence to guidelines and reduced inefficient variation in prescribing.
Management of COPD in the UK primary-care setting: an analysis of real-life prescribing patterns

PubMed Central

Price, David; West, Daniel; Brusselle, Guy; Gruffydd-Jones, Kevin; Jones, Rupert; Miravitlles, Marc; Rossi, Andrea; Hutton, Catherine; Ashton, Valerie L; Stewart, Rebecca; Bichel, Katsiaryna

2014-01-01

Background Despite the availability of national and international guidelines, evidence suggests that chronic obstructive pulmonary disease (COPD) treatment is not always prescribed according to recommendations. This study evaluated the current management of patients with COPD using a large UK primary-care database. Methods This analysis used electronic patient records and patient-completed questionnaires from the Optimum Patient Care Research Database. Data on current management were analyzed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) group and presence or absence of a concomitant asthma diagnosis, in patients with a COPD diagnosis at ≥35 years of age and with spirometry results supportive of the COPD diagnosis. Results A total of 24,957 patients were analyzed, of whom 13,557 (54.3%) had moderate airflow limitation (GOLD Stage 2 COPD). The proportion of patients not receiving pharmacologic treatment for COPD was 17.0% in the total COPD population and 17.7% in the GOLD Stage 2 subset. Approximately 50% of patients in both cohorts were receiving inhaled corticosteroids (ICS), either in combination with a long-acting β2-agonist (LABA; 26.7% for both cohorts) or a LABA and a long-acting muscarinic antagonist (LAMA; 23.2% and 19.9%, respectively). ICS + LABA and ICS + LABA + LAMA were the most frequently used treatments in GOLD Groups A and B. Of patients without concomitant asthma, 53.7% of the total COPD population and 50.2% of the GOLD Stage 2 subset were receiving ICS. Of patients with GOLD Stage 2 COPD and no exacerbations in the previous year, 49% were prescribed ICS. A high proportion of GOLD Stage 2 COPD patients were symptomatic on their current management (36.6% with modified Medical Research Council score ≥2; 76.4% with COPD Assessment Test score ≥10). Conclusion COPD is not treated according to GOLD and National Institute for Health and Care Excellence recommendations in the UK primary-care setting. Some patients receive no treatment despite experiencing symptoms. Among those on treatment, most receive ICS irrespective of severity of airflow limitation, asthma diagnosis, and exacerbation history. Many patients on treatment continue to have symptoms. PMID:25210450
Multidisciplinary approaches to managing osteoarthritis in multiple joint sites: a systematic review.

PubMed

Finney, Andrew; Healey, Emma; Jordan, Joanne L; Ryan, Sarah; Dziedzic, Krysia S

2016-07-08

The National Institute for Health and Care Excellence's Osteoarthritis (OA) guidelines recommended that future research should consider the benefits of combination therapies in people with OA across multiple joint sites. However, the clinical effectiveness of such approaches to OA management is unknown. This systematic review therefore aimed to identify the clinical and cost effectiveness of multidisciplinary approaches targeting multiple joint sites for OA in primary care. A systematic review of randomised controlled trials. Computerised bibliographic databases were searched (MEDLINE, EMBASE, CINAHL, PsychINFO, BNI, HBE, HMIC, AMED, Web of Science and Cochrane). Studies were included if they met the following criteria; a randomised controlled trial (RCT), a primary care population with OA across at least two different peripheral joint sites (multiple joint sites), and interventions undertaken by at least two different health disciplines (multidisciplinary). The Cochrane 'Risk of Bias' tool and PEDro were used for quality assessment of eligible studies. Clinical and cost effectiveness was determined by extracting and examining self-reported outcomes for pain, function, quality of life (QoL) and health care utilisation. The date range for the search was from database inception until August 2015. The search identified 1148 individual titles of which four were included in the review. A narrative review was conducted due to the heterogeneity of the included trials. Each of the four trials used either educational or exercise interventions facilitated by a range of different health disciplines. Moderate clinical benefits on pain, function and QoL were reported across the studies. The beneficial effects of exercise generally decreased over time within all studies. Two studies were able to show a reduction in healthcare utilisation due to a reduction in visits to a physiotherapist or a reduction in x-rays and orthopaedic referrals. The intervention that showed the most promise used educational interventions delivered by GPs with reinforcement by practice nurses. There are currently very few studies that target multidisciplinary approaches suitable for OA across multiple joint sites, in primary care. A more consistent approach to outcome measurement in future studies of this nature should be considered to allow for better comparison.
What are the Implications for Policy Makers? A Systematic Review of the Cost-Effectiveness of Screening and Brief Interventions for Alcohol Misuse in Primary Care

PubMed Central

Angus, Colin; Latimer, Nicholas; Preston, Louise; Li, Jessica; Purshouse, Robin

2014-01-01

Introduction: The efficacy of screening and brief interventions (SBIs) for excessive alcohol use in primary care is well established; however, evidence on their cost-effectiveness is limited. A small number of previous reviews have concluded that SBI programs are likely to be cost-effective but these results are equivocal and important questions around the cost-effectiveness implications of key policy decisions such as staffing choices for delivery of SBIs and the intervention duration remain unanswered. Methods: Studies reporting both the costs and a measure of health outcomes of programs combining SBIs in primary care were identified by searching MEDLINE, EMBASE, Econlit, the Cochrane Library Database (including NHS EED), CINAHL, PsycINFO, Assia and the Social Science Citation Index, and Science Citation Index via Web of Knowledge. Included studies have been stratified both by delivery staff and intervention duration and assessed for quality using the Drummond checklist for economic evaluations. Results: The search yielded a total of 23 papers reporting the results of 22 distinct studies. There was significant heterogeneity in methods and outcome measures between studies; however, almost all studies reported SBI programs to be cost-effective. There was no clear evidence that either the duration of the intervention or the delivery staff used had a substantial impact on this result. Conclusion: This review provides strong evidence that SBI programs in primary care are a cost-effective option for tackling alcohol misuse. PMID:25225487
No physician gender difference in prescription of sick-leave certification: A retrospective study of the Skaraborg Primary Care Database

PubMed Central

Starzmann, Karin; Hjerpe, Per; Dalemo, Sofia; Björkelund, Cecilia; Boström, Kristina Bengtsson

2012-01-01

Objective The primary objective was to investigate how physicians’ gender and level of experience affects the rate and length of sick-leave certificate prescription. The secondary objective was to study the physicians’ gender and professional experience in relation to the diagnoses on the certificates. Design Retrospective, cross-sectional study of computerized medical records from 24 health care centres in 2005. Setting Primary care in Sweden. Subjects Primary care physicians (n = 589) and patients (n = 88 780) aged 18–64 years. Main outcome measures Rate and duration of sick leave certified by different categories of physicians and for different diagnoses and gender of patients. Results Sick leave was certified in 9.0% (musculoskeletal (3%) and psychiatric (2.3%) diagnoses were most common) of all contacts and the mean duration was 32.2 days. Overall there was no difference between male and female physicians in the sick-leave certification prescription rate (9.1% vs. 9.0%) or duration of sick leave (32.1 vs. 32.6 days). The duration of sick leave was associated with the physician's level of professional experience in general practice (GPs (Distriktläkare) 37, GP trainees (ST-läkare) 26, interns (AT-läkare) 20 and locum (vikarier) 19 days, p < 0.001). Conclusion Contrary to earlier studies we found no difference in sick-leave certification prescription rate and length between male and female physicians. PMID:22348513
Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence.

PubMed

Seah, Richard; Mani-Babu, Sivanadian

2011-01-01

To summarize the best available evidence in the last decade for managing ankle sprains in the community, data were collected using MEDLINE database from January 2000 to December 2009. Terms utilized: 'ankle injury primary care' (102 articles were found), 'ankle sprain primary care' (34 articles), 'ankle guidelines primary care' (25 articles), 'ankle pathways primary care' (2 articles), 'ankle sprain community' (18 articles), 'ankle sprain general practice' (22 articles), 'Cochrane review ankle' (58 articles). Of these, only 33 satisfied the inclusion criteria. The search terms identified many of the same studies. Two independent reviewers reviewed the articles. The study results and generated conclusions were extracted, discussed and finally agreed on. Ankle sprains occur commonly but their management is not always readily agreed. The Ottawa Ankle Rules are ubiquitous in the clinical pathway and can be reliably applied by emergency care physicians, primary care physicians and triage nurses. For mild-to-moderate ankle sprains, functional treatment options (which can consist of elastic bandaging, soft casting, taping or orthoses with associated coordination training) were found to be statistically better than immobilization for multiple outcome measures. For severe ankle sprains, a short period of immobilization in a below-knee cast or pneumatic brace results in a quicker recovery than tubular compression bandage alone. Lace-up supports are a more effective functional treatment than elastic bandaging and result in less persistent swelling in the short term when compared with semi-rigid ankle supports, elastic bandaging and tape. Semi-rigid orthoses and pneumatic braces provide beneficial ankle support and may prevent subsequent sprains during high-risk sporting activity. Supervised rehabilitation training in combination with conventional treatment for acute lateral ankle sprains can be beneficial, although some of the studies reviewed gave conflicting outcomes. Therapeutic hyaluronic acid injections in the ankle are a relatively novel non-surgical treatment but may have a role in expediting return to sport after ankle sprain. There is a role for surgical intervention in severe acute and chronic ankle injuries, but the evidence is limited.
Clinical data integration model. Core interoperability ontology for research using primary care data.

PubMed

Ethier, J-F; Curcin, V; Barton, A; McGilchrist, M M; Bastiaens, H; Andreasson, A; Rossiter, J; Zhao, L; Arvanitis, T N; Taweel, A; Delaney, B C; Burgun, A

2015-01-01

This article is part of the Focus Theme of METHODS of Information in Medicine on "Managing Interoperability and Complexity in Health Systems". Primary care data is the single richest source of routine health care data. However its use, both in research and clinical work, often requires data from multiple clinical sites, clinical trials databases and registries. Data integration and interoperability are therefore of utmost importance. TRANSFoRm's general approach relies on a unified interoperability framework, described in a previous paper. We developed a core ontology for an interoperability framework based on data mediation. This article presents how such an ontology, the Clinical Data Integration Model (CDIM), can be designed to support, in conjunction with appropriate terminologies, biomedical data federation within TRANSFoRm, an EU FP7 project that aims to develop the digital infrastructure for a learning healthcare system in European Primary Care. TRANSFoRm utilizes a unified structural / terminological interoperability framework, based on the local-as-view mediation paradigm. Such an approach mandates the global information model to describe the domain of interest independently of the data sources to be explored. Following a requirement analysis process, no ontology focusing on primary care research was identified and, thus we designed a realist ontology based on Basic Formal Ontology to support our framework in collaboration with various terminologies used in primary care. The resulting ontology has 549 classes and 82 object properties and is used to support data integration for TRANSFoRm's use cases. Concepts identified by researchers were successfully expressed in queries using CDIM and pertinent terminologies. As an example, we illustrate how, in TRANSFoRm, the Query Formulation Workbench can capture eligibility criteria in a computable representation, which is based on CDIM. A unified mediation approach to semantic interoperability provides a flexible and extensible framework for all types of interaction between health record systems and research systems. CDIM, as core ontology of such an approach, enables simplicity and consistency of design across the heterogeneous software landscape and can support the specific needs of EHR-driven phenotyping research using primary care data.

A systematic review of clinician and staff views on the acceptability of incorporating remote monitoring technology into primary care.

PubMed

Davis, Melinda M; Freeman, Michele; Kaye, Jeffrey; Vuckovic, Nancy; Buckley, David I

2014-05-01

Remote monitoring technology (RMT) may enhance healthcare quality and reduce costs. RMT adoption depends on perceptions of the end-user (e.g., patients, caregivers, healthcare providers). We conducted a systematic review exploring the acceptability and feasibility of RMT use in routine adult patient care, from the perspectives of primary care clinicians, administrators, and clinic staff. We searched the databases of Medline, IEEE Xplore, and Compendex for original articles published from January 1996 through February 2013. We manually screened bibliographies of pertinent studies and consulted experts to identify English-language studies meeting our inclusion criteria. Of 939 citations identified, 15 studies reported in 16 publications met inclusion criteria. Studies were heterogeneous by country, type of RMT used, patient and provider characteristics, and method of implementation and evaluation. Clinicians, staff, and administrators generally held positive views about RMTs. Concerns emerged regarding clinical relevance of RMT data, changing clinical roles and patterns of care (e.g., reduced quality of care from fewer patient visits, overtreatment), insufficient staffing or time to monitor and discuss RMT data, data incompatibility with a clinic's electronic health record (EHR), and unclear legal liability regarding response protocols. This small body of heterogeneous literature suggests that for RMTs to be adopted in primary care, researchers and developers must ensure clinical relevance, support adequate infrastructure, streamline data transmission into EHR systems, attend to changing care patterns and professional roles, and clarify response protocols. There is a critical need to engage end-users in the development and implementation of RMT.
A Systematic Review of Clinician and Staff Views on the Acceptability of Incorporating Remote Monitoring Technology into Primary Care

PubMed Central

Freeman, Michele; Kaye, Jeffrey; Vuckovic, Nancy; Buckley, David I.

2014-01-01

Abstract Objective: Remote monitoring technology (RMT) may enhance healthcare quality and reduce costs. RMT adoption depends on perceptions of the end-user (e.g., patients, caregivers, healthcare providers). We conducted a systematic review exploring the acceptability and feasibility of RMT use in routine adult patient care, from the perspectives of primary care clinicians, administrators, and clinic staff. Materials and Methods: We searched the databases of Medline, IEEE Xplore, and Compendex for original articles published from January 1996 through February 2013. We manually screened bibliographies of pertinent studies and consulted experts to identify English-language studies meeting our inclusion criteria. Results: Of 939 citations identified, 15 studies reported in 16 publications met inclusion criteria. Studies were heterogeneous by country, type of RMT used, patient and provider characteristics, and method of implementation and evaluation. Clinicians, staff, and administrators generally held positive views about RMTs. Concerns emerged regarding clinical relevance of RMT data, changing clinical roles and patterns of care (e.g., reduced quality of care from fewer patient visits, overtreatment), insufficient staffing or time to monitor and discuss RMT data, data incompatibility with a clinic's electronic health record (EHR), and unclear legal liability regarding response protocols. Conclusions: This small body of heterogeneous literature suggests that for RMTs to be adopted in primary care, researchers and developers must ensure clinical relevance, support adequate infrastructure, streamline data transmission into EHR systems, attend to changing care patterns and professional roles, and clarify response protocols. There is a critical need to engage end-users in the development and implementation of RMT. PMID:24731239
Frequent users of the Royal Flying Doctor Service primary clinic and aeromedical services in remote New South Wales: a quality study.

PubMed

Garne, David L; Perkins, David A; Boreland, Frances T; Lyle, David M

To examine activity patterns of the Royal Flying Doctor Service of Australia (RFDS) in far western New South Wales and to determine whether frequent use of RFDS services, particularly emergency evacuations, is a useful indicator of patients who may benefit from care planning and review. We conducted a retrospective audit of the RFDS South Eastern Section's Broken Hill patient database. Patients with a residential address in the study area who had accessed at least one RFDS medical service between 1 July 2000 and 30 June 2005 were included in the study. Number of evacuations, clinic consultations and remote consultations; clinic usage by frequent evacuees; number of primary diagnoses recorded for frequent evacuees; number of frequent users who might benefit from multidisciplinary care or specialist shared care. Between July 2000 and June 2005, the number of residents requiring evacuation or remote consultations declined by 26% and 19%, respectively, and the number of residents accessing clinics declined by 6%. (Over the same period, the population of the study area fell by about 24%.) Of the 78 patients who were identified as frequent users of the evacuation service (> or = 3 evacuations/year), 34 had three or more primary diagnoses recorded; 15 were infrequent or non-users of the clinics (< or = 3 attendances/year); 53 may have benefited from multidisciplinary care, and 41 from specialist shared care. Simple, practical clinical review systems can help health care organisations in rural and remote communities to achieve better outcomes by identifying patients who may benefit from planned care.
Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review

PubMed Central

Rushforth, Bruno; McCrorie, Carolyn; Glidewell, Liz; Midgley, Eleanor; Foy, Robbie

2016-01-01

Background Despite the availability of evidence-based guidance, many patients with type 2 diabetes do not achieve treatment goals. Aim To guide quality improvement strategies for type 2 diabetes by synthesising qualitative evidence on primary care physicians’ and nurses’ perceived influences on care. Design and setting Systematic review of qualitative studies with findings organised using the Theoretical Domains Framework. Method Databases searched were MEDLINE, Embase, CINAHL, PsycInfo, and ASSIA from 1980 until March 2014. Studies included were English-language qualitative studies in primary care of physicians’ or nurses’ perceived influences on treatment goals for type 2 diabetes. Results A total of 32 studies were included: 17 address general diabetes care, 11 glycaemic control, three blood pressure, and one cholesterol control. Clinicians struggle to meet evolving treatment targets within limited time and resources, and are frustrated with resulting compromises. They lack confidence in knowledge of guidelines and skills, notably initiating insulin and facilitating patient behaviour change. Changing professional boundaries have resulted in uncertainty about where clinical responsibility resides. Accounts are often couched in emotional terms, especially frustrations over patient compliance and anxieties about treatment intensification. Conclusion Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than ‘one size fits all’ approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians’ skills and emotions around treatment intensification and facilitation of patient behaviour change. PMID:26823263
Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review.

PubMed

Rushforth, Bruno; McCrorie, Carolyn; Glidewell, Liz; Midgley, Eleanor; Foy, Robbie

2016-02-01

Despite the availability of evidence-based guidance, many patients with type 2 diabetes do not achieve treatment goals. To guide quality improvement strategies for type 2 diabetes by synthesising qualitative evidence on primary care physicians' and nurses' perceived influences on care. Systematic review of qualitative studies with findings organised using the Theoretical Domains Framework. Databases searched were MEDLINE, Embase, CINAHL, PsycInfo, and ASSIA from 1980 until March 2014. Studies included were English-language qualitative studies in primary care of physicians' or nurses' perceived influences on treatment goals for type 2 diabetes. A total of 32 studies were included: 17 address general diabetes care, 11 glycaemic control, three blood pressure, and one cholesterol control. Clinicians struggle to meet evolving treatment targets within limited time and resources, and are frustrated with resulting compromises. They lack confidence in knowledge of guidelines and skills, notably initiating insulin and facilitating patient behaviour change. Changing professional boundaries have resulted in uncertainty about where clinical responsibility resides. Accounts are often couched in emotional terms, especially frustrations over patient compliance and anxieties about treatment intensification. Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than 'one size fits all' approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians' skills and emotions around treatment intensification and facilitation of patient behaviour change. © British Journal of General Practice 2016.
Enhancing adult therapeutic interpersonal relationships in the acute health care setting: an integrative review

PubMed Central

Kornhaber, Rachel; Walsh, Kenneth; Duff, Jed; Walker, Kim

2016-01-01

Therapeutic interpersonal relationships are the primary component of all health care interactions that facilitate the development of positive clinician–patient experiences. Therapeutic interpersonal relationships have the capacity to transform and enrich the patients’ experiences. Consequently, with an increasing necessity to focus on patient-centered care, it is imperative for health care professionals to therapeutically engage with patients to improve health-related outcomes. Studies were identified through an electronic search, using the PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO databases of peer-reviewed research, limited to the English language with search terms developed to reflect therapeutic interpersonal relationships between health care professionals and patients in the acute care setting. This study found that therapeutic listening, responding to patient emotions and unmet needs, and patient centeredness were key characteristics of strategies for improving therapeutic interpersonal relationships. PMID:27789958
Enhancing adult therapeutic interpersonal relationships in the acute health care setting: an integrative review.

PubMed

Kornhaber, Rachel; Walsh, Kenneth; Duff, Jed; Walker, Kim

2016-01-01

Therapeutic interpersonal relationships are the primary component of all health care interactions that facilitate the development of positive clinician-patient experiences. Therapeutic interpersonal relationships have the capacity to transform and enrich the patients' experiences. Consequently, with an increasing necessity to focus on patient-centered care, it is imperative for health care professionals to therapeutically engage with patients to improve health-related outcomes. Studies were identified through an electronic search, using the PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO databases of peer-reviewed research, limited to the English language with search terms developed to reflect therapeutic interpersonal relationships between health care professionals and patients in the acute care setting. This study found that therapeutic listening, responding to patient emotions and unmet needs, and patient centeredness were key characteristics of strategies for improving therapeutic interpersonal relationships.
End-of-Life Care Interventions: An Economic Analysis

PubMed Central

Pham, B; Krahn, M

2014-01-01

Background The annual cost of providing care for patients in their last year of life is estimated to account for approximately 9% of the Ontario health care budget. Access to integrated, comprehensive support and pain/symptom management appears to be inadequate and inequitable. Objective To evaluate the cost-effectiveness of end-of-life (EoL) care interventions included in the EoL care mega-analysis. Data Sources Multiple sources were used, including systematic reviews, linked health administration databases, survey data, planning documents, expert input, and additional literature searches. Review Methods We conducted a literature review of cost-effectiveness studies to inform the primary economic analysis. We conducted the primary economic analysis and budget impact analysis for an Ontario cohort of decedents and their families and included interventions pertaining to team-based models of care, patient care planning discussions, educational interventions for patients and caregivers, and supportive interventions for informal caregivers. The time horizon was the last year of life. Costs were in 2013 Canadian dollars. Effectiveness measures included days at home, percentage dying at home, and quality-adjusted life-days. We developed a Markov model; model inputs were obtained from a cohort of Ontario decedents assembled from Institute for Clinical Evaluative Sciences databases and published literature. Results In-home palliative team care was cost-effective; it increased the chance of dying at home by 10%, increased the average number of days at home (6 days) and quality-adjusted life-days (0.5 days), and it reduced costs by approximately $4,400 per patient. Expanding in-home palliative team care to those currently not receiving such services (approximately 45,000 per year, at an annual cost of $76–108 million) is likely to improve quality of life, reduce the use of acute care resources, and save $191–$385 million in health care costs. Results for the other interventions were uncertain. Limitations The cost-effectiveness analysis was based in part on the notion that resources allocated to EoL care interventions were designed to maximize quality-adjusted life-years (QALY) for patients and their family, but improving QALYs may not be the intended aim of EoL interventions. Conclusions In-home palliative team care was cost-effective, but firm conclusions about the cost-effectiveness of other interventions were not possible. PMID:26339303
End-of-Life Care Interventions: An Economic Analysis.

PubMed

Pham, B; Krahn, M

2014-01-01

The annual cost of providing care for patients in their last year of life is estimated to account for approximately 9% of the Ontario health care budget. Access to integrated, comprehensive support and pain/symptom management appears to be inadequate and inequitable. To evaluate the cost-effectiveness of end-of-life (EoL) care interventions included in the EoL care mega-analysis. Multiple sources were used, including systematic reviews, linked health administration databases, survey data, planning documents, expert input, and additional literature searches. We conducted a literature review of cost-effectiveness studies to inform the primary economic analysis. We conducted the primary economic analysis and budget impact analysis for an Ontario cohort of decedents and their families and included interventions pertaining to team-based models of care, patient care planning discussions, educational interventions for patients and caregivers, and supportive interventions for informal caregivers. The time horizon was the last year of life. Costs were in 2013 Canadian dollars. Effectiveness measures included days at home, percentage dying at home, and quality-adjusted life-days. We developed a Markov model; model inputs were obtained from a cohort of Ontario decedents assembled from Institute for Clinical Evaluative Sciences databases and published literature. In-home palliative team care was cost-effective; it increased the chance of dying at home by 10%, increased the average number of days at home (6 days) and quality-adjusted life-days (0.5 days), and it reduced costs by approximately $4,400 per patient. Expanding in-home palliative team care to those currently not receiving such services (approximately 45,000 per year, at an annual cost of $76-108 million) is likely to improve quality of life, reduce the use of acute care resources, and save $191-$385 million in health care costs. Results for the other interventions were uncertain. The cost-effectiveness analysis was based in part on the notion that resources allocated to EoL care interventions were designed to maximize quality-adjusted life-years (QALY) for patients and their family, but improving QALYs may not be the intended aim of EoL interventions. In-home palliative team care was cost-effective, but firm conclusions about the cost-effectiveness of other interventions were not possible.
Enablers and barriers to implementing collaborative care for anxiety and depression: a systematic qualitative review.

PubMed

Overbeck, Gritt; Davidsen, Annette Sofie; Kousgaard, Marius Brostrøm

2016-12-28

Collaborative care is an increasingly popular approach for improving quality of care for people with mental health problems through an intensified and structured collaboration between primary care providers and health professionals with specialized psychiatric expertise. Trials have shown significant positive effects for patients suffering from depression, but since collaborative care is a complex intervention, it is important to understand the factors which affect its implementation. We present a qualitative systematic review of the enablers and barriers to implementing collaborative care for patients with anxiety and depression. We developed a comprehensive search strategy in cooperation with a research librarian and performed a search in five databases (EMBASE, PubMed, PsycINFO, ProQuest, and CINAHL). All authors independently screened titles and abstracts and reviewed full-text articles. Studies were included if they were published in English and based on the original qualitative data on the implementation of a collaborative care intervention targeted at depression or anxiety in an adult patient population in a high-income country. Our subsequent analysis employed the normalization process theory (NPT). We included 17 studies in our review of which 11 were conducted in the USA, five in the UK, and one in Canada. We identified several barriers and enablers within the four major analytical dimensions of NPT. Securing buy-in among primary care providers was found to be critical but sometimes difficult. Enablers included physician champions, reimbursement for extra work, and feedback on the effectiveness of collaborative care. The social and professional skills of the care managers seemed critical for integrating collaborative care in the primary health care clinic. Day-to-day implementation was also found to be facilitated by the care managers being located in the clinic since this supports regular face-to-face interactions between physicians and care managers. The following areas require special attention when planning collaborative care interventions: effective educational programs, especially for care managers; issues of reimbursement in relation to primary care providers; good systems for communication and monitoring; and promoting face-to-face interaction between care managers and physicians, preferably through co-location. There is a need for well-sampled, in-depth qualitative studies on the implementation of collaborative care in settings outside the USA and the UK.
Antihypertensive treatment and control according to gender, education, country of birth and psychiatric disorder: the Swedish Primary Care Cardiovascular Database (SPCCD).

PubMed

Ljungman, C; Kahan, T; Schiöler, L; Hjerpe, P; Wettermark, B; Boström, K B; Manhem, K

2015-06-01

The reasons why women and men are treated with different antihypertensive drugs are not clear. Whether socioeconomic factors influence prescription patterns and blood pressure control differently in women and men has not been investigated. This cross-sectional study performed in a cohort of hypertensive patients from the Swedish Primary Care Cardiovascular Database (SPCCD) examined the influence of educational level, country of birth, gender and concomitant psychiatric disorder on prescription pattern and blood pressure control in 40,825 hypertensive patients. Men were more often than women treated with calcium channel blocker and angiotensin-converting enzyme inhibitor (ACEI), irrespective of education, country of birth and psychiatric disorder. Educational level influenced the prescription pattern to some extent, where the gender differences were reduced in patients with a higher educational level. In women, but not in men, high educational level and concomitant psychiatric disorder were associated with a higher proportion reaching target blood pressure. The predominant use of ACEI and calcium channel blockers in men is not influenced by educational level, country of birth or psychiatric disorder. Thus other explanations must be considered such as gender differences in side effects. Educational level seems to have a greater impact on reaching target blood pressure in women compared with men.
The effect of the global financial crisis on preventable hospitalizations among the homeless in New York State.

PubMed

White, Brandi; Ellis, Charles; Jones, Walter; Moran, William; Simpson, Kit

2018-04-01

Objective Periods of economic instability may increase preventable hospitalizations because of increased barriers to accessing primary care. For underserved populations such as the homeless, these barriers may be more pronounced due to limited resources in the health care safety net. This study examined the impact of the global financial crisis of 2007-2008 on access to care for the homeless in New York State. Methods Hospitalizations for ambulatory care sensitive conditions (ACSCs) were used as a proxy measure for primary care access. Admissions for ACSCs were identified in the New York State Inpatient Database from 2006 to 2012. Hospitalization rates for ACSCs were calculated for the homeless and nonhomeless. Multivariable linear regression was used to investigate the impact of the financial crisis on hospitalization rates for ACSCs. Results The findings indicate that during the financial crisis, homeless adults had significantly higher preventable hospitalizations than nonhomeless adults, and the uninsured homeless had significantly higher preventable hospitalizations when compared to other homeless subgroups. After the financial crisis, preventable hospitalizations for the homeless stabilized but remained at higher rates than those for the nonhomeless. Conclusions These findings are important to developing health policies designed to provide effective care for underserved population such as the homeless.
New graduate registered nurse transition into primary health care roles: an integrative literature review.

PubMed

Murray-Parahi, Pauline; DiGiacomo, Michelle; Jackson, Debra; Davidson, Patricia M

2016-11-01

To summarise the literature describing new graduate nurse transition to professional practice within the primary health care (PHC) setting. There is a plethora of research literature spanning several decades about new graduate nurse transition in the acute care setting. Yet, the experiences of new graduate nurse in the PHC setting is unremarkable particularly considering the increasing demand for skilled health care workers and focus of health reform to provide care where people work and live. Electronic data bases, Academic Search Complete, EBSCO, Medline, PsycINFO, CINHAL, and ERIC were searched using a combination of terms and synonyms arising from three key concepts which identify the phenomenon; 'transition', 'new graduate registered nurse' and 'primary health care. An inclusive search strategy placed no limits on language or publication date. Of the 50 articles located and examined for relevance; 40 were sourced through databases and 10 from Google Scholar/Alerts and hand-searching references. None of the 19 articles retained for analysis addressed all key concepts. Some challenges of researching the professional transition of graduate nurses in PHC settings included, an absence of definitive transition models, a dearth of literature and deference to acute care research. Nursing in PHC settings, particularly the client's home is notably different to hospital settings because of higher levels of isolation and autonomy. Societal changes, health reform and subsequent demand for skilled workers in PHC settings has caused health care providers to question the logic that such roles are only for experienced nurses. Implications arise for education and health service providers who desire to close the theory practice gap and mitigate risk for all stakeholders when next generation nurses have limited opportunities to experience PHC roles as undergraduates and newly graduated registered nurses are already transitioning in this setting. © 2016 John Wiley & Sons Ltd.
International practice settings, interventions and outcomes of nurse practitioners in geriatric care: A scoping review.

PubMed

Chavez, Krista S; Dwyer, Andrew A; Ramelet, Anne-Sylvie

2018-02-01

To identify and summarize the common clinical settings, interventions, and outcomes of nurse practitioner care specific to older people. Scoping review of the international published and grey literature. A structured literature search was conducted of CINAHL, EMBASE, MEDLINE, Google Scholar, and Cochrane Collaboration and Joanna Briggs Institute databases. Following the Arksey and O'Malley framework, randomized controlled and quasi-experimental studies of Masters-prepared nurse practitioners providing care for patients over 65 years were included. Studies were reviewed independently by two investigators. Data were extracted, collated by setting, summarized in tables and synthesized for analysis. In total, 56 primary research studies from four countries and 23 systematic reviews were identified. Primary studies were conducted in primary care (n=13), home care (n=14), long-term care (n=10), acute/hospital care (n=9), and transitional care (n=10). Nurse practitioner interventions included substitutive as well as a supplementation NP role elements to meet specific unmet patient care needs. Studies examined six main outcome measures: service utilization (n=41), cost (n=24), length of stay (n=14), health indices (n=44), satisfaction (n=14) and quality of life (n=7). Cumulatively, nurse practitioners demonstrated enhanced results in 83/144 (58%) of outcomes compared to physician-only or usual care. The most commonly measured financial-related outcome was service utilization (n=41) and benefits were frequently reported in home care (8/9, 89%) and long-term care (7/10, 70%) settings. Among patient and care-related outcomes health indices were most frequently measured (n=44). Primary care most frequently reported improved health indices (11/13, 85%). Transitional care reported improved outcomes across all measures, except for service utilization. This review demonstrates improved or non-inferiority results of nurse practitioner care in older people across settings. More well-designed, rigorous studies are needed particularly in relation to costs. The results of this review could be used for future systemic review of effectiveness of NP care specific to older people. Despite the demonstrated NP role value, barriers to implementing the nurse practitioner role persist internationally and more work is needed to develop and promote these roles. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.
Resilience of primary healthcare professionals: a systematic review

PubMed Central

Robertson, Helen D; Elliott, Alison M; Burton, Christopher; Iversen, Lisa; Murchie, Peter; Porteous, Terry; Matheson, Catriona

2016-01-01

Background Modern demands and challenges among healthcare professionals can be particularly stressful and resilience is increasingly necessary to maintain an effective, adaptable, and sustainable workforce. However, definitions of, and associations with, resilience have not been examined within the primary care context. Aim To examine definitions and measures of resilience, identify characteristics and components, and synthesise current evidence about resilience in primary healthcare professionals. Design and setting A systematic review was undertaken to identify studies relating to the primary care setting. Method Ovid®, Embase®, CINAHL, PsycINFO, and Scopus databases were searched in December 2014. Text selections and data extraction were conducted by paired reviewers working independently. Data were extracted on health professional resilience definitions and associated factors. Results Thirteen studies met the inclusion criteria: eight were quantitative, four qualitative, and one was an intervention study. Resilience, although multifaceted, was commonly defined as involving positive adaptation to adversity. Interactions were identified between personal growth and accomplishment in resilient physicians. Resilience, high persistence, high self-directedness, and low avoidance of challenges were strongly correlated; resilience had significant associations with traits supporting high function levels associated with demanding health professional roles. Current resilience measures do not allow for these different aspects in the primary care context. Conclusion Health professional resilience is multifaceted, combining discrete personal traits alongside personal, social, and workplace features. A measure for health professional resilience should be developed and validated that may be used in future quantitative research to measure the effect of an intervention to promote it. PMID:27162208
Resilience of primary healthcare professionals: a systematic review.

PubMed

Robertson, Helen D; Elliott, Alison M; Burton, Christopher; Iversen, Lisa; Murchie, Peter; Porteous, Terry; Matheson, Catriona

2016-06-01

Modern demands and challenges among healthcare professionals can be particularly stressful and resilience is increasingly necessary to maintain an effective, adaptable, and sustainable workforce. However, definitions of, and associations with, resilience have not been examined within the primary care context. To examine definitions and measures of resilience, identify characteristics and components, and synthesise current evidence about resilience in primary healthcare professionals. A systematic review was undertaken to identify studies relating to the primary care setting. Ovid(®), Embase(®), CINAHL, PsycINFO, and Scopus databases were searched in December 2014. Text selections and data extraction were conducted by paired reviewers working independently. Data were extracted on health professional resilience definitions and associated factors. Thirteen studies met the inclusion criteria: eight were quantitative, four qualitative, and one was an intervention study. Resilience, although multifaceted, was commonly defined as involving positive adaptation to adversity. Interactions were identified between personal growth and accomplishment in resilient physicians. Resilience, high persistence, high self-directedness, and low avoidance of challenges were strongly correlated; resilience had significant associations with traits supporting high function levels associated with demanding health professional roles. Current resilience measures do not allow for these different aspects in the primary care context. Health professional resilience is multifaceted, combining discrete personal traits alongside personal, social, and workplace features. A measure for health professional resilience should be developed and validated that may be used in future quantitative research to measure the effect of an intervention to promote it. © British Journal of General Practice 2016.
A review of near patient testing in primary care.

PubMed

Hobbs, F D; Delaney, B C; Fitzmaurice, D A; Wilson, S; Hyde, C J; Thorpe, G H; Earl-Slater, A S; Jowett, S; Tobias, R S

1997-01-01

The aim was to identify publications relating to near patient testing (NPT), the use of alternative delivery systems between laboratory and general practice, including electronic data interchange (EDI), and computerised diagnostic decision support (CDDS), in the primary care setting to answer the following questions. What is the availability of NPT for primary care? What evidence is available to support the clinical effectiveness of NPT? What evidence is available on the accuracy and reliability of NPT within primary care? What evidence is available on the cost-effectiveness of different NPTs? How may CDDS improve the effectiveness of NPT? What evidence is available that compares NPT and existing laboratory services? What evidence is available on the cost-effectiveness of EDI or alternative delivery systems? Eight databases were searched, and the bibliographies from relevant publications checked for completeness. Unpublished work and publications not included in the databases were obtained by personal contact with collaborators, and from a postal survey sent to heads of academic departments of general practice and clinical chemistry and to researchers active or interested in the field worldwide. Questionnaires were also sent to 150 commercial organisations. Publications that met agreed definitions and reported original data were included in the systematic review. Of the 1057 publications identified, 102 (92 related to NPT, eight to CDDS, and two to EDI) were passed to the reviewers for appraisal of validity. The limited amount of published research relating to any particular NPT prohibited meta-analysis. Scoring systems to assess the validity of evaluations were also difficult to apply. A wide variety of NPT systems have been developed. In general, the quality of the methods reported in the literature was poor. The issue of patient convenience and acceptability has not been adequately addressed. No evaluations of alternative delivery systems met the review criteria. No studies have evaluated the telephone or fax machine as a means of reporting results. For EDI, the majority of papers were descriptive. EDI and alternative delivery systems are not a replacement for NPT when the provision of an immediate result might have an impact on the quality of care. EDI may have clinical and cost advantages over traditional means of communication, but this has not been evaluated. The advisory role of the laboratory can be supported by CDDS. The use of CDDS and NPT has not, however, been fully evaluated. Few economic analyses have been conducted, and most were simple cost analyses. There are insufficient data for conclusions to be drawn on the cost-effectiveness of NPT in primary care. FURTHER SYSTEMATIC REVIEWS: Subject-specific systematic reviews are required that include laboratory and secondary care studies, and consider the potential for altering current management and patient acceptability. Priority topics include: biochemistry profiles on desktop analysers; cholesterol testing; urinalysis for the diagnosis of urinary tract infection; anticoagulation control; NPTs for the identification of acute infection. (ABSTRACT TRUNCATED)
A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination.

PubMed

Joshi, Chandni; Russell, Grant; Cheng, I-Hao; Kay, Margaret; Pottie, Kevin; Alston, Margaret; Smith, Mitchell; Chan, Bibiana; Vasi, Shiva; Lo, Winston; Wahidi, Sayed Shukrullah; Harris, Mark F

2013-11-07

Refugees have many complex health care needs which should be addressed by the primary health care services, both on their arrival in resettlement countries and in their transition to long-term care. The aim of this narrative synthesis is to identify the components of primary health care service delivery models for such populations which have been effective in improving access, quality and coordination of care. A systematic review of the literature, including published systematic reviews, was undertaken. Studies between 1990 and 2011 were identified by searching Medline, CINAHL, EMBASE, Cochrane Library, Scopus, Australian Public Affairs Information Service - Health, Health and Society Database, Multicultural Australian and Immigration Studies and Google Scholar. A limited snowballing search of the reference lists of all included studies was also undertaken. A stakeholder advisory committee and international advisers provided papers from grey literature. Only English language studies of evaluated primary health care models of care for refugees in developed countries of resettlement were included. Twenty-five studies met the inclusion criteria for this review of which 15 were Australian and 10 overseas models. These could be categorised into six themes: service context, clinical model, workforce capacity, cost to clients, health and non-health services. Access was improved by multidisciplinary staff, use of interpreters and bilingual staff, no-cost or low-cost services, outreach services, free transport to and from appointments, longer clinic opening hours, patient advocacy, and use of gender-concordant providers. These services were affordable, appropriate and acceptable to the target groups. Coordination between the different health care services and services responding to the social needs of clients was improved through case management by specialist workers. Quality of care was improved by training in cultural sensitivity and appropriate use of interpreters. The elements of models most frequently associated with improved access, coordination and quality of care were case management, use of specialist refugee health workers, interpreters and bilingual staff. These findings have implications for workforce planning and training.
A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination

PubMed Central

2013-01-01

Introduction Refugees have many complex health care needs which should be addressed by the primary health care services, both on their arrival in resettlement countries and in their transition to long-term care. The aim of this narrative synthesis is to identify the components of primary health care service delivery models for such populations which have been effective in improving access, quality and coordination of care. Methods A systematic review of the literature, including published systematic reviews, was undertaken. Studies between 1990 and 2011 were identified by searching Medline, CINAHL, EMBASE, Cochrane Library, Scopus, Australian Public Affairs Information Service – Health, Health and Society Database, Multicultural Australian and Immigration Studies and Google Scholar. A limited snowballing search of the reference lists of all included studies was also undertaken. A stakeholder advisory committee and international advisers provided papers from grey literature. Only English language studies of evaluated primary health care models of care for refugees in developed countries of resettlement were included. Results Twenty-five studies met the inclusion criteria for this review of which 15 were Australian and 10 overseas models. These could be categorised into six themes: service context, clinical model, workforce capacity, cost to clients, health and non-health services. Access was improved by multidisciplinary staff, use of interpreters and bilingual staff, no-cost or low-cost services, outreach services, free transport to and from appointments, longer clinic opening hours, patient advocacy, and use of gender-concordant providers. These services were affordable, appropriate and acceptable to the target groups. Coordination between the different health care services and services responding to the social needs of clients was improved through case management by specialist workers. Quality of care was improved by training in cultural sensitivity and appropriate use of interpreters. Conclusion The elements of models most frequently associated with improved access, coordination and quality of care were case management, use of specialist refugee health workers, interpreters and bilingual staff. These findings have implications for workforce planning and training. PMID:24199588
An overview and methodological assessment of systematic reviews and meta-analyses of enhanced recovery programmes in colorectal surgery

PubMed Central

Chambers, Duncan; Paton, Fiona; Wilson, Paul; Eastwood, Alison; Craig, Dawn; Fox, Dave; Jayne, David; McGinnes, Erika

2014-01-01

Objectives To identify and critically assess the extent to which systematic reviews of enhanced recovery programmes for patients undergoing colorectal surgery differ in their methodology and reported estimates of effect. Design Review of published systematic reviews. We searched the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) Database from 1990 to March 2013. Systematic reviews of enhanced recovery programmes for patients undergoing colorectal surgery were eligible for inclusion. Primary and secondary outcome measures The primary outcome was length of hospital stay. We assessed changes in pooled estimates of treatment effect over time and how these might have been influenced by decisions taken by researchers as well as by the availability of new trials. The quality of systematic reviews was assessed using the Centre for Reviews and Dissemination (CRD) DARE critical appraisal process. Results 10 systematic reviews were included. Systematic reviews of randomised controlled trials have consistently shown a reduction in length of hospital stay with enhanced recovery compared with traditional care. The estimated effect tended to increase from 2006 to 2010 as more trials were published but has not altered significantly in the most recent review, despite the inclusion of several unique trials. The best estimate appears to be an average reduction of around 2.5 days in primary postoperative length of stay. Differences between reviews reflected differences in interpretation of inclusion criteria, searching and analytical methods or software. Conclusions Systematic reviews of enhanced recovery programmes show a high level of research waste, with multiple reviews covering identical or very similar groups of trials. Where multiple reviews exist on a topic, interpretation may require careful attention to apparently minor differences between reviews. Researchers can help readers by acknowledging existing reviews and through clear reporting of key decisions, especially on inclusion/exclusion and on statistical pooling. PMID:24879828

Clinical effects of blood donor characteristics in transfusion recipients: protocol of a framework to study the blood donor–recipient continuum

PubMed Central

Chassé, Michaël; McIntyre, Lauralyn; Tinmouth, Alan; Acker, Jason; English, Shane W; Knoll, Greg; Forster, Alan; Shehata, Nadine; Wilson, Kumanan; van Walraven, Carl; Ducharme, Robin; Fergusson, Dean A

2015-01-01

Introduction When used appropriately, transfusion of red blood cells (RBCs) is a necessary life-saving therapy. However, RBC transfusions have been associated with negative outcomes such as infection and organ damage. Seeking explanations for the beneficial and deleterious effects of RBC transfusions is necessary to ensure the safe and optimal use of this precious resource. This study will create a framework to analyse the influence of blood donor characteristics on recipient outcomes. Methods and analysis We will conduct a multisite, longitudinal cohort study using blood donor data routinely collected by Canadian Blood Services, and recipient data from health administrative databases. Our project will include a thorough validation of primary data, the linkage of various databases into one large longitudinal database, an in-depth epidemiological analysis and a careful interpretation and dissemination of the results to assist the decision-making process of clinicians, researchers and policymakers in transfusion medicine. Our primary donor characteristic will be age of blood donors and our secondary donor characteristics will be donor–recipient blood group compatibility and blood donor sex. Our primary recipient outcome will be a statistically appropriate survival analysis post-RBC transfusion up to a maximum of 8 years. Our secondary recipient outcomes will include 1-year, 2-year and 5-year mortality; hospital and intensive care unit length of stay; rehospitalisation; new cancer and cancer recurrence rate; infection rate; new occurrence of myocardial infarctions and need for haemodialysis. Ethics and dissemination Our results will help determine whether we need to tailor transfusion based on donor characteristics, and perhaps this will improve patient outcome. Our results will be customised to target the different stakeholders involved with blood transfusions and will include presentations, peer-reviewed publications and the use of the dissemination network of blood supply organisations. We obtained approval from the Research Ethics boards and privacy offices of all involved institutions. PMID:25600255
Evaluating the effectiveness, impact and safety of live attenuated and seasonal inactivated influenza vaccination: protocol for the Seasonal Influenza Vaccination Effectiveness II (SIVE II) study

PubMed Central

Lone, Nazir I; Kavanagh, Kimberley; Robertson, Chris; McMenamin, Jim; von Wissmann, Beatrix; Vasileiou, Eleftheria; Butler, Chris; Ritchie, Lewis D; Gunson, Rory; Schwarze, Jürgen; Sheikh, Aziz

2017-01-01

Introduction Seasonal (inactivated) influenza vaccination is recommended for all individuals aged 65+ and in individuals under 65 who are at an increased risk of complications of influenza infection, for example, people with asthma. Live attenuated influenza vaccine (LAIV) was recommended for children as they are thought to be responsible for much of the transmission of influenza to the populations at risk of serious complications from influenza. A phased roll-out of the LAIV pilot programme began in 2013/2014. There is limited evidence for vaccine effectiveness (VE) in the populations targeted for influenza vaccination. The aim of this study is to examine the safety and effectiveness of the live attenuated seasonal influenza vaccine programme in children and the inactivated seasonal influenza vaccination programme among different age and at-risk groups of people. Methods and analysis Test negative and cohort study designs will be used to estimate VE. A primary care database covering 1.25 million people in Scotland for the period 2000/2001 to 2015/2016 will be linked to the Scottish Immunisation Recall Service (SIRS), Health Protection Scotland virology database, admissions to Scottish hospitals and the Scottish death register. Vaccination status (including LAIV uptake) will be determined from the primary care and SIRS database. The primary outcome will be influenza-positive real-time PCR tests carried out in sentinel general practices and other healthcare settings. Secondary outcomes include influenza-like illness and asthma-related general practice consultations, hospitalisations and death. An instrumental variable analysis will be carried out to account for confounding. Self-controlled study designs will be used to estimate the risk of adverse events associated with influenza vaccination. Ethics and dissemination We obtained approval from the National Research Ethics Service Committee, West Midlands—Edgbaston. The study findings will be presented at international conferences and published in peer-reviewed journals. Trial registration number ISRCTN88072400; Pre-results. PMID:28246142
Creating collaborative learning environments for transforming primary care practices now.

PubMed

Miller, William L; Cohen-Katz, Joanne

2010-12-01

The renewal of primary care waits just ahead. The patient-centered medical home (PCMH) movement and a refreshing breeze of collaboration signal its arrival with demonstration projects and pilots appearing across the country. An early message from this work suggests that the development of collaborative, cross-disciplinary teams may be essential for the success of the PCMH. Our focus in this article is on training existing health care professionals toward being thriving members of this transformed clinical care team in a relationship-centered PCMH. Our description of the optimal conditions for collaborative training begins with delineating three types of teams and how they relate to levels of collaboration. We then describe how to create a supportive, safe learning environment for this type of training, using a different model of professional socialization, and tools for building culture. Critical skills related to practice development and the cross-disciplinary collaborative processes are also included. Despite significant obstacles in readying current clinicians to be members of thriving collaborative teams, a few next steps toward implementing collaborative training programs for existing professionals are possible using competency-based and adult learning approaches. Grasping the long awaited arrival of collaborative primary health care will also require delivery system and payment reform. Until that happens, there is an abundance of work to be done envisioning new collaborative training programs and initiating a nation-wide effort to motivate and reeducate our colleagues. PsycINFO Database Record (c) 2010 APA, all rights reserved.
Plenty of activity but little outcome data: a review of the "grey literature" on primary care anxiety and depression programs in Australia.

PubMed

Christensen, Helen; Griffiths, Kathleen M; Gulliver, Amelia

2008-06-16

To identify reports in the "grey literature" of programs conducted in Australian primary care to improve depression and anxiety outcomes, and to examine these reports for evidence of effectiveness. A systematic search was undertaken for grey literature reports using primary health care research databases, community and professional websites, clearinghouse sources, government reports, and reports from the Australian General Practice Network. Reports were included if they related to programs targeting depression or anxiety, contained qualitative or quantitative effectiveness data, and were published during 1995-2006. In total, 642 reports were identified, of which 43 met inclusion criteria. Of the 43 programs described, 30 were delivered in general practice, five in the community or residential care, three in schools, and five were Internet or computer based. Nine programs were also reported in the formal "black" literature, but most, including the Better Outcomes in Mental Health Care initiative, were not. Limited data on effectiveness or patient outcomes were available in the grey literature. There is currently no single service that identifies, describes and catalogues the range and effectiveness of mental health initiatives in Australia. There may be a role for a mental health information "clearinghouse" to facilitate dissemination and education, and to promote collaboration among researchers, practitioners, consumers and policymakers. Innovative schemes to disseminate evidence-based models and to encourage the collection of data on patient outcomes in such programs are needed.
Necessity and feasibility of improving mental health services in China: A systematic qualitative review.

PubMed

Zhao, Xudong; Liu, Liang; Hu, Chengping; Chen, Fazhan; Sun, Xirong

2017-07-01

It has been nearly 40 years since the reform and opening up of Mainland China. The mental health services system has developed rapidly as a part of the profound socioeconomic changes that ensued. However, its development has not been as substantial as other areas of medical care. For the current qualitative systematic review, we searched databases, including China Biology Medicine disc, Weipu, China National Knowledge Infrastructure, Wanfang digital periodical full text data, China's important newspaper full text database, China Statistical Yearbook database, etc. The content of primary research, literature, and policy papers about the evolution and development of Chinese mental health services was systemically reviewed and analysed by using thematic analysis. Two main themes relative to the necessity and feasibility of reforming the current mental health services system emerged. We discuss 5 corresponding subthemes under the umbrella of the necessity of improving the current treatment, rehabilitation, prevention, and service systems and 7 requirements for the feasibility of reforming the current system. We conclude that as the development of the Chinese economy and the spirit of humanistic care continue, the improvement and reformation of the mental health services system are both necessary and feasible. Copyright © 2017 John Wiley & Sons, Ltd.
Desiderata for a Computer-Assisted Audit Tool for Clinical Data Source Verification Audits

PubMed Central

Duda, Stephany N.; Wehbe, Firas H.; Gadd, Cynthia S.

2013-01-01

Clinical data auditing often requires validating the contents of clinical research databases against source documents available in health care settings. Currently available data audit software, however, does not provide features necessary to compare the contents of such databases to source data in paper medical records. This work enumerates the primary weaknesses of using paper forms for clinical data audits and identifies the shortcomings of existing data audit software, as informed by the experiences of an audit team evaluating data quality for an international research consortium. The authors propose a set of attributes to guide the development of a computer-assisted clinical data audit tool to simplify and standardize the audit process. PMID:20841814
Laboratory testing in primary care: A systematic review of health IT impacts.

PubMed

Maillet, Éric; Paré, Guy; Currie, Leanne M; Raymond, Louis; Ortiz de Guinea, Ana; Trudel, Marie-Claude; Marsan, Josianne

2018-08-01

Laboratory testing in primary care is a fundamental process that supports patient management and care. Any breakdown in the process may alter clinical information gathering and decision-making activities and can lead to medical errors and potential adverse outcomes for patients. Various information technologies are being used in primary care with the goal to support the process, maximize patient benefits and reduce medical errors. However, the overall impact of health information technologies on laboratory testing processes has not been evaluated. To synthesize the positive and negative impacts resulting from the use of health information technology in each phase of the laboratory 'total testing process' in primary care. We conducted a systematic review. Databases including Medline, PubMed, CINAHL, Web of Science and Google Scholar were searched. Studies eligible for inclusion reported empirical data on: 1) the use of a specific IT system, 2) the impacts of the systems to support the laboratory testing process, and were conducted in 3) primary care settings (including ambulatory care and primary care offices). Our final sample consisted of 22 empirical studies which were mapped to a framework that outlines the phases of the laboratory total testing process, focusing on phases where medical errors may occur. Health information technology systems support several phases of the laboratory testing process, from ordering the test to following-up with patients. This is a growing field of research with most studies focusing on the use of information technology during the final phases of the laboratory total testing process. The findings were largely positive. Positive impacts included easier access to test results by primary care providers, reduced turnaround times, and increased prescribed tests based on best practice guidelines. Negative impacts were reported in several studies: paper-based processes employed in parallel to the electronic process increased the potential for medical errors due to clinicians' cognitive overload; systems deemed not reliable or user-friendly hampered clinicians' performance; and organizational issues arose when results tracking relied on the prescribers' memory. The potential of health information technology lies not only in the exchange of health information, but also in knowledge sharing among clinicians. This review has underscored the important role played by cognitive factors, which are critical in the clinician's decision-making, the selection of the most appropriate tests, correct interpretation of the results and efficient interventions. By providing the right information, at the right time to the right clinician, many IT solutions adequately support the laboratory testing process and help primary care clinicians make better decisions. However, several technological and organizational barriers require more attention to fully support the highly fragmented and error-prone process of laboratory testing. Copyright © 2018 Elsevier B.V. All rights reserved.
Treatment patterns and healthcare resource utilization and costs in heavy menstrual bleeding: a Japanese claims database analysis.

PubMed

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

2018-06-01

Heavy menstrual bleeding (HMB) is a highly prevalent condition, characterized by excessive menstrual blood loss and cramping, that interferes with activities of daily life. The aim of this study was to investigate treatment patterns in HMB in Japan, and to assess healthcare resource utilization and costs among women newly-diagnosed with the condition. This study retrospectively analyzed health insurance data available in the Japan Medical Data Center (JMDC) database on women aged 18-49 years who were newly-diagnosed with primary or secondary HMB. Treatment patterns were analyzed, and healthcare utilization and costs were evaluated and compared to matched controls. The study included a total of 635 patients, 210 with primary HMB and 425 with secondary HMB. In the primary HMB cohort, 60.0% of patients received one or more pharmacological or surgical treatments, compared with 76.2% in the secondary HMB cohort. The most commonly prescribed medications in all patients were hemostatic agents (28.7%), traditional Chinese medicine (TCM) (12.1%), and low-dose estrogen progestins (LEPs) (10.1%). After adjustment for patient baseline characteristics, healthcare costs were 1.93-times higher in primary HMB cases (p < .0001) and 4.44-times higher in secondary HMB cases (p < .0001) vs healthy controls. Outpatient care was the main cost driver. The main limitations of this study are related to its retrospective nature, and the fact that only reimbursed medications were captured in the source database. A substantial proportion of HMB patients did not receive the recommended treatments. Healthcare costs were considerably increased in the presence of an HMB diagnosis.
[Ethical problems experienced by nurses in primary health care: integrative literature review].

PubMed

Nora, Carlise Rigon Dalla; Zoboli, Elma Lourdes Campos Pavone; Vieira, Margarida

2015-03-01

The aim of this study is to identify ethical problems experienced by nurses in primary health care and resources for coping based on publications on the subject. An integrative literature review was performed between the months of October and November 2013, using the databases: BDTD, CINAHL, LILACS, MEDLINE, Biblioteca Cochrane, PubMed, RCAAP and SciELO. Articles, dissertations and theses published in Portuguese, English and Spanish were included, totalling 31 studies published from 1992 to 2013. This analysis resulted in four categories: ethical problems in the relationship between team members, ethical problems in the relationship with the user, ethical problems in health services management and resources for coping with ethical problems. Results showed that nurses need to be prepared to face ethical problems, emphasizing the importance of ethics education during the education process before and during professional practice to enhance the development of ethical sensitivity and competence for problem resolution.
Launching forward: The integration of behavioral health in primary care as a key strategy for promoting young child wellness.

PubMed

Oppenheim, Jennifer; Stewart, Whitney; Zoubak, Ekaterina; Donato, Ingrid; Huang, Larke; Hudock, William

2016-03-01

In 2008, the Substance Abuse and Mental Health Services Administration (SAMHSA) created a national grant program, Project LAUNCH (Linking Actions for Unmet Needs in Children's Health), to improve behavioral health and developmental outcomes for young children through the incorporation of prevention and wellness promotion practices in key early childhood settings. Project LAUNCH supports states, tribal nations, and territories to improve coordination across early childhood systems and implement 5 core strategies of prevention and promotion. This article focuses on the lessons learned from 1 of the 5 core strategies: integration of behavioral health into primary care for young children. This paper analyzes the experiences of a sample of Project LAUNCH grantees, describing 10 common elements of integration approaches and exploring some of the challenges of promoting health and preventing social, emotional, and behavioral problems at a population level. (PsycINFO Database Record (c) 2016 APA, all rights reserved).
Integrating care coordination home telehealth and home based primary care in rural Oklahoma: a pilot study.

PubMed

Sorocco, Kristen H; Bratkovich, Kristi L; Wingo, Rita; Qureshi, Saleem M; Mason, Patrick J

2013-08-01

The purpose of this program was to evaluate the benefits of integrating VA Care Coordination Home Telehealth and Telemental health within HBPC. A case study design was used to determine quality assurance and quality improvement of incorporating additional home telehealth equipment within Home Based Primary Care (HBPC). Veterans with complex medical conditions and their caregivers living in rural Oklahoma were enrolled. Veterans received the same care other HBPC patients received with the addition of home telehealth equipment. Members from the interdisciplinary treatment team were certified to use the telehealth equipment. Veterans and their caregivers were trained on use of the equipment in their homes. Standard HBPC program measures were used to assess the program success. Assessments from all disciplines on the HBPC team were at baseline, 3, and 6 months, and participants provided satisfaction and interview data to assess the benefits of integrating technology into standard care delivery within an HBPC program. Six veterans were enrolled (mean age = 72 yrs) with a range of physical health conditions including: chronic obstructive pulmonary disease, cerebrovascular accident, spinal cord injury, diabetes, hypertension, and syncope. Primary mental health conditions included depression, dementia, anxiety, and PTSD. Scores on the Mini-Mental State Examination ranged from 18 to 30. Over a 6-month period, case studies indicated improvements in strength, social functioning, decreased caregiver burden, and compliance with treatment plan. This integration of CCHT and HBPC served previously underserved rural veterans having complex medical conditions and appears both feasible and clinically beneficial to veterans and their caregivers. PsycINFO Database Record (c) 2013 APA, all rights reserved.
Is an opportunistic primary care-based intervention for non-responders to bowel screening feasible and acceptable? A mixed-methods feasibility study in Scotland

PubMed Central

Calanzani, Natalia; Cavers, Debbie; Vojt, Gabriele; Orbell, Sheina; Steele, Robert J C; Brownlee, Linda; Smith, Steve; Patnick, Julietta; Weller, David; Campbell, Christine

2017-01-01

Objectives We aimed to test whether a brief, opportunistic intervention in general practice was a feasible and acceptable way to engage with bowel screening non-responders. Design This was a feasibility study testing an intervention which comprised a brief conversation during routine consultation, provision of a patient leaflet and instructions to request a replacement faecal occult blood test kit. A mixed-methods approach to evaluation was adopted. Data were collected from proformas completed after each intervention, from the Bowel Screening Centre database and from questionnaires. Semi-structured interviews were carried out. We used descriptive statistics, content and framework analysis to determine intervention feasibility and acceptability. Participants Bowel screening non-responders (as defined by the Scottish Bowel Screening Centre) and primary care professionals working in five general practices in Lothian, Scotland. Primary and secondary outcome measures Several predefined feasibility parameters were assessed, including numbers of patients engaging in conversation, requesting a replacement kit and returning it, and willingness of primary care professionals to deliver the intervention. Results The intervention was offered to 258 patients in five general practices: 220 (87.0%) engaged with the intervention, 60 (23.3%) requested a new kit, 22 (8.5%) kits were completed and returned. Interviews and questionnaires suggest that the intervention was feasible, acceptable and consistent with an existing health prevention agenda. Reported challenges referred to work-related pressures, time constraints and practice priorities. Conclusions This intervention was acceptable and resulted in a modest increase in non-responders participating in bowel screening, although outlined challenges may affect sustained implementation. The strategy is also aligned with the increasing role of primary care in promoting bowel screening. PMID:29025829
Nurses' perceptions of ethical issues in the care of older people.

PubMed

Rees, Jenny; King, Lindy; Schmitz, Karl

2009-07-01

The aim of this thematic literature review is to explore nurses' perceptions of ethical issues in the care of older people. Electronic databases were searched from September 1997 to September 2007 using specific key words with tight inclusion criteria, which revealed 17 primary research reports. The data analysis involved repeated reading of the findings and sorting of those findings into four themes. These themes are: sources of ethical issues for nurses; differences in perceptions between nurses and patients/relatives; nurses' personal responses to ethical issues; and the patient-nurse relationship. The findings reveal that ageism is one of the major sources of the ethical issues that arise for nurses caring for older people. Education and organizational change can combat ageist attitudes. Wider training is required in the care of older people, workplace skills, palliative care and pain management for older people. The demands of a changing global demography will necessitate further research in this field.
Small-area variation in screening for cancer, glucose and cholesterol in Ontario: a cross-sectional study.

PubMed

Fernandes, Kimberly A; Sutradhar, Rinku; Borkhoff, Cornelia M; Baxter, Nancy; Lofters, Aisha; Rabeneck, Linda; Tinmouth, Jill; Paszat, Lawrence

2015-01-01

Screening for cervical, breast and colon cancers, and elevations of cholesterol and glucose, reduces premature cause-specific mortality from these cancers and circulatory diseases. Despite primary care reforms and incentives, and promotion of cancer-screening programs among individuals, participation is suboptimal. We aimed to examine participation as of Dec. 31, 2011, by factors of deprivation, demographics and primary care at the small-area level. From health care administrative databases, we identified people eligible for each screening test, and their participation, in each dissemination area (referred to as small areas, n = 18 950) in Ontario. We calculated rates for each test among small areas (overall and stratified by demographic, socioeconomic and primary care descriptors) and stratified by sex for all tests combined. We loaded all data into a geographic information system. Funnel plots were generated showing the percentage of eligible people who completed screening for all tests by small area, stratified by sex. Overall and stratified screening prevalence ratios were calculated among small areas. Among small areas, the mean and SD for participation in all tests combined was 31.6% (SD 11.0%) for women and 41.2% (SD 12.0%) for men. Screening prevalence among small areas, for each test and for all tests combined, overall and stratified by sex, declined with decreasing percentage with high school completion, decreasing socioeconomic quintile, and decreasing percentage with an identifiable primary care physician. Our results show that the rate of participation in all eligible screening tests among small areas is much lower than the rate of participation in any one particular test. This finding has implications for the design and implementation of strategies to improve rates of screening.
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
Predicting meaningful outcomes to medication and self-help treatments for binge-eating disorder in primary care: The significance of early rapid response.

PubMed

Grilo, Carlos M; White, Marney A; Masheb, Robin M; Gueorguieva, Ralitza

2015-04-01

We examined rapid response among obese patients with binge-eating disorder (BED) in a randomized clinical trial testing antiobesity medication and self-help cognitive-behavioral therapy (shCBT), alone and in combination, in primary-care settings. One hundred four obese patients with BED were randomly assigned to 1 of 4 treatments: sibutramine, placebo, shCBT + sibutramine, or shCBT + placebo. Treatments were delivered by generalist primary-care physicians and the medications were given double-blind. Independent assessments were performed by trained and monitored doctoral research clinicians monthly throughout treatment, posttreatment (4 months), and at 6- and 12-month follow-ups (i.e., 16 months after randomization). Rapid response, defined as ≥65% reduction in binge eating by the fourth treatment week, was used to predict outcomes. Rapid response characterized 47% of patients, was unrelated to demographic and baseline clinical characteristics, and was significantly associated, prospectively, with remission from binge eating at posttreatment (51% vs. 9% for nonrapid responders), 6-month (53% vs. 23.6%), and 12-month (46.9% vs. 23.6%) follow-ups. Mixed-effects model analyses revealed that rapid response was significantly associated with greater decreases in binge-eating or eating-disorder psychopathology, depression, and percent weight loss. Our findings, based on a diverse obese patient group receiving medication and shCBT for BED in primary-care settings, indicate that patients who have a rapid response achieve good clinical outcomes through 12-month follow-ups after ending treatment. Rapid response represents a strong prognostic indicator of clinically meaningful outcomes, even in low-intensity medication and self-help interventions. Rapid response has important clinical implications for stepped-care treatment models for BED. clinicaltrials.gov: NCT00537810 (PsycINFO Database Record (c) 2015 APA, all rights reserved).
County-level correlation between adult obesity rates and prevalence of dentists.

PubMed

Holzer, Jessica; Canavan, Maureen; Bradley, Elizabeth

2014-09-01

Investigators of previous studies regarding the correlation between area-level health care resources and obesity have not examined the association between the prevalence of dentists and rates of adult obesity. The authors conducted a study to address that knowledge gap. Using data compiled in the Robert Wood Johnson County Health Rankings and Roadmaps database, the authors conducted multivariable analyses of the relationship between the prevalence of dentists (from the 2011 Health Resources and Services Administration Area Resource File) and rates of obesity within counties. The authors controlled for prevalence of primary care providers, measures of the built environment (for example, number of recreational facilities per 10,000 population, the percentage of restaurants serving fast food) and county-level sociodemographic and economic factors. When the authors conducted a multivariable analysis adjusted for state-level fixed effects, they found that having one additional dentist per 10,000 population was associated significantly with a 1-percentage point reduction in the rate of obesity (P < .001). This effect was significantly larger in counties in which 25 percent of children or more (versus less than 25 percent of children) lived in poverty and in counties that had more primary care physicians per 10,000 population (P ≤ .009). The association between the prevalence of dentists and obesity, even after adjusting for primary care resources and sociodemographic factors, was evident. Although these data could not be used to assess causality, given the strength of the ecological, cross-sectional association, additional research involving person-level, longitudinal data is warranted. The correlation between the prevalence of dentists and obesity rates highlights the potential for dental professionals, as well as other primary care providers, to provide meaningful health education and support for improved nutritional behaviors, although the increased obesity rates in counties with fewer dentists per capita present challenges.
Using linked administrative and disease-specific databases to study end-of-life care on a population level.

PubMed

Maetens, Arno; De Schreye, Robrecht; Faes, Kristof; Houttekier, Dirk; Deliens, Luc; Gielen, Birgit; De Gendt, Cindy; Lusyne, Patrick; Annemans, Lieven; Cohen, Joachim

2016-10-18

The use of full-population databases is under-explored to study the use, quality and costs of end-of-life care. Using the case of Belgium, we explored: (1) which full-population databases provide valid information about end-of-life care, (2) what procedures are there to use these databases, and (3) what is needed to integrate separate databases. Technical and privacy-related aspects of linking and accessing Belgian administrative databases and disease registries were assessed in cooperation with the database administrators and privacy commission bodies. For all relevant databases, we followed procedures in cooperation with database administrators to link the databases and to access the data. We identified several databases as fitting for end-of-life care research in Belgium: the InterMutualistic Agency's national registry of health care claims data, the Belgian Cancer Registry including data on incidence of cancer, and databases administrated by Statistics Belgium including data from the death certificate database, the socio-economic survey and fiscal data. To obtain access to the data, approval was required from all database administrators, supervisory bodies and two separate national privacy bodies. Two Trusted Third Parties linked the databases via a deterministic matching procedure using multiple encrypted social security numbers. In this article we describe how various routinely collected population-level databases and disease registries can be accessed and linked to study patterns in the use, quality and costs of end-of-life care in the full population and in specific diagnostic groups.
Advances and challenges in oral health after a decade of the “Smiling Brazil” Program

PubMed Central

Scherer, Charleni Inês; Scherer, Magda Duarte dos Anjos

2016-01-01

ABSTRACT OBJECTIVE To analyze oral health work changes in primary health care after Brazil’s National Oral Health Policy Guidelines were released. METHODS A literature review was conducted on Medline, LILACS, Embase, SciELO, Biblioteca Virtual em Saúde, and The Cochrane Library databases, from 2000 to 2013, on elements to analyze work changes. The descriptors used included: primary health care, family health care, work, health care policy, oral health care services, dentistry, oral health, and Brazil. Thirty-two studies were selected and analyzed, with a predominance of qualitative studies from the Northeast region with workers, especially dentists, focusing on completeness and quality of care. RESULTS Observed advances focused on educational and permanent education actions; on welcoming, bonding, and accountability. The main challenges were related to completeness; extension and improvement of care; integrated teamwork; working conditions; planning, monitoring, and evaluation of actions; stimulating people’s participation and social control; and intersectorial actions. CONCLUSIONS Despite the new regulatory environment, there are very few changes in oral health work. Professionals tend to reproduce the dominant biomedical model. Continuing efforts will be required in work management, training, and permanent education fields. Among the possibilities are the increased engagement of managers and professionals in a process to understand work dynamics and training in the perspective of building significant changes for local realities. PMID:26815162
Chronic care model for the management of depression: synthesis of barriers to, and facilitators of, success.

PubMed

Holm, Anne Lise; Severinsson, Elisabeth

2012-12-01

Depression is a socially- and physically-disabling condition. The Chronic Care Model (CCM) was developed to promote better management of long-term conditions, such as depression, in primary care settings. The aim of the study was to identify barriers to, and facilitators of, success when implementing the CCM for the management of depression in primary care. A systematic search was conducted in electronic databases from January 2005 to December 2011. Thirteen articles met the inclusion criteria and were reviewed by means of a thematic analysis. The barriers were categorized under two themes: lack of organizational, administrative, and professional ability to change and implement the components of the CCM; and lack of clarity pertaining to the responsibility inherent in the role of care manager (often a nurse) when it comes to promoting the patient's self-management ability. In terms of the facilitators of success, two themes emerged: leadership support and vision, and redesigning the delivery system. When shaping an environment for organizational change, leadership and professionals must work towards a common goal and vision. Such processes require a care manager with a clear role and responsibilities in order for the health-care system to meet the needs of the person with depression. © 2012 The Authors. International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.

Payment reform in the patient-centered medical home: Enabling and sustaining integrated behavioral health care.

PubMed

Miller, Benjamin F; Ross, Kaile M; Davis, Melinda M; Melek, Stephen P; Kathol, Roger; Gordon, Patrick

2017-01-01

The patient-centered medical home (PCMH) is a promising framework for the redesign of primary care and more recently specialty care. As defined by the Agency for Healthcare Research and Quality, the PCMH framework has 5 attributes: comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety. Evidence increasingly demonstrates that for the PCMH to best achieve the Triple Aim (improved outcomes, decreased cost, and enhanced patient experience), treatment for behavioral health (including mental health, substance use, and life stressors) must be integrated as a central tenet. However, challenges to implementing the PCMH framework are compounded for real-world practitioners because payment reform rarely happens concurrently. Nowhere is this more evident than in attempts to integrate behavioral health clinicians into primary care. As behavioral health clinicians find opportunities to work in integrated settings, a comprehensive understanding of payment models is integral to the dialogue. This article describes alternatives to the traditional fee for service (FFS) model, including modified FFS, pay for performance, bundled payments, and global payments (i.e., capitation). We suggest that global payment structures provide the best fit to enable and sustain integrated behavioral health clinicians in ways that align with the Triple Aim. Finally, we present recommendations that offer specific, actionable steps to achieve payment reform, complement PCMH, and support integration efforts through policy. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
Smart home technologies for health and social care support.

PubMed

Martin, Suzanne; Kelly, Greg; Kernohan, W George; McCreight, Bernadette; Nugent, Christopher

2008-10-08

The integration of smart home technology to support health and social care is acquiring an increasing global significance. Provision is framed within the context of a rapidly changing population profile, which is impacting on the number of people requiring health and social care, workforce availability and the funding of healthcare systems. To explore the effectiveness of smart home technologies as an intervention for people with physical disability, cognitive impairment or learning disability, who are living at home, and to consider the impact on the individual's health status and on the financial resources of health care. We searched the following databases for primary studies: (a) the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register, (b) the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library, issue 1, 2007), and (c) bibliographic databases, including MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007) and CINAHL (1982 to March 2007). We also searched the Database of Abstracts of Reviews of Effectiveness (DARE). We searched the electronic databases using a strategy developed by the EPOC Trials Search Co-ordinator. We included randomised controlled trials (RCTs), quasi-experimental studies, controlled before and after studies (CBAs) and interrupted time series analyses (ITS). Participants included adults over the age of 18, living in their home in a community setting. Participants with a physical disability, dementia or a learning disability were included. The included interventions were social alarms, electronic assistive devices, telecare social alert platforms, environmental control systems, automated home environments and 'ubiquitous homes'. Outcome measures included any objective measure that records an impact on a participant's quality of life, healthcare professional workload, economic outcomes, costs to healthcare provider or costs to participant. We included measures of service satisfaction, device satisfaction and healthcare professional attitudes or satisfaction. One review author completed the search strategy with the support of a life and health sciences librarian. Two review authors independently screened titles and abstracts of results. No studies were identified which met the inclusion criteria. This review highlights the current lack of empirical evidence to support or refute the use of smart home technologies within health and social care, which is significant for practitioners and healthcare consumers.
Primary care interventions to reduce cardiovascular risk behaviours in adolescents: a protocol for a systematic review.

PubMed

Haller, Dagmar M; Pfarrwaller, Eva; Cerutti, Bernard; Gaspoz, Jean-Michel

2016-10-18

Health-compromising behaviours are often acquired in adolescence. Alongside broader public health interventions, preventive interventions within primary care have the potential to encourage long-lasting behaviour change by tailoring messages to each individual. The aim of this study is to determine the effectiveness of primary care interventions in reducing the 3 main cardiovascular risk behaviours (smoking, low physical activity and unhealthy diet) in adolescents aged 10-19 years. It is also to identify successful initiatives and ingredients for such success that could be replicated in primary care. This systematic review of the literature and meta-analysis will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The following databases will be searched for articles published between January 1990 and December 2016: MEDLINE, EMBASE, PsychINFO, CINAHL, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, ISRCTN registry. Our search will focus on randomised and cluster randomised controlled trials of interventions conducted in primary care practices to reduce the 3 main cardiovascular risk behaviours in adolescents aged 10-19 years, compared with active (information leaflet, etc) or passive (usual care, etc) control conditions. The primary outcomes will be smoking, physical activity and diet, measured either objectively or by self-report. Secondary outcomes such as body mass index or insulin resistance will also be examined. 2 reviewers will independently screen articles, extract relevant data and assess study quality using the Cochrane risk of bias tool. A meta-analysis will be considered if the number of studies is sufficient and outcomes are sufficiently homogeneous. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria will be used to assess the quality of the evidence. This systematic review will add to our knowledge on the prevention of cardiovascular disease early in life and these findings will be disseminated through peer-reviewed publications and presentations at relevant conferences. PROSPERO CRD42016028045. 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/.
Defining adolescent common mental disorders using electronic primary care data: a comparison with outcomes measured using the CIS-R.

PubMed

Cornish, Rosie P; John, Ann; Boyd, Andy; Tilling, Kate; Macleod, John

2016-12-01

To compare the prevalence of common mental disorders (CMDs) derived from data held in primary care records with that measured using the revised Clinical Interview Schedule (CIS-R) in order to assess the potential robustness of findings based only on routinely collected data. Comparison study using linkage between the Avon Longitudinal Study of Parents and Children (ALSPAC) and electronic primary care records. We studied 1562 adolescents who had completed the CIS-R in ALSPAC at age 17-18 years and had linkage established to their primary care records. Outcome measures from ALSPAC were whether or not an individual met International Classification of Diseases-10 criteria for a diagnosis of (1) a CMD or, specifically, (2) depression. Lists of Read codes corresponding to diagnoses, symptoms and treatments were used to create 12 definitions of CMD and depression alone using the primary care data. We calculated sensitivities and specificities of these, using CIS-R definitions as the reference standard. Sensitivities ranged from 5.2% to 24.3% for depression and from 3.8% to 19.2% for CMD. The specificities of all definitions were above 98% for depression and above 96% for CMD.For both outcomes, the definition that included current diagnosis, treatment or symptoms identified the highest proportion of CIS-R cases. Most individuals meeting case definitions for CMD based on primary care data also met CIS-R case definitions. Conversely many individuals identified as cases using the CIS-R had no evidence of CMD in their clinical records. This suggests that clinical databases are likely to yield underestimates of the burden of CMD in the population. However, clinical records appear to yield valid diagnoses which may be useful for studying risk factors and consequences of CMD. The greatest epidemiological value may be obtained when information is available from survey and clinical records. 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/.
Primary care interventions and current service innovations in modifying long-term outcomes after stroke: a protocol for a scoping review

PubMed Central

Pindus, Dominika M; Lim, Lisa; Rundell, A Viona; Hobbs, Victoria; Aziz, Noorazah Abd; Mullis, Ricky; Mant, Jonathan

2016-01-01

Introduction Interventions delivered by primary and/or community care have the potential to reach the majority of stroke survivors and carers and offer ongoing support. However, an integrative account emerging from the reviews of interventions addressing specific long-term outcomes after stroke is lacking. The aims of the proposed scoping review are to provide an overview of: (1) primary care and community healthcare interventions by generalist healthcare professionals to stroke survivors and/or their informal carers to address long-term outcomes after stroke, (2) the scope and characteristics of interventions which were successful in addressing long-term outcomes, and (3) developments in current clinical practice. Methods and analysis Studies that focused on adult community dwelling stroke survivors and informal carers were included. Academic electronic databases will be searched to identify reviews of randomised controlled trials (RCTs) and controlled trials, trials from the past 5 years; reviews of observational studies. Practice exemplars from grey literature will be identified through advanced Google search. Reports, guidelines and other documents of major health organisations, clinical professional bodies, and stroke charities in the UK and internationally will be included. Two reviewers will independently screen titles, abstracts and full texts for inclusion of published literature. One reviewer will screen search results from the grey literature and identify relevant documents for inclusion. Data synthesis will include analysis of the number, type of studies, year and country of publication, a summary of intervention components/service or practice, outcomes addressed, main results (an indicator of effectiveness) and a description of included interventions. Ethics and dissemination The review will help identify components of care and care pathways for primary care services for stroke. By comparing the results with stroke survivors' and carers' needs identified in the literature, the review will highlight potential gaps in research and practice relevant to long-term care after stroke. PMID:27798023
Use of electronic health records by child primary healthcare providers in Europe.

PubMed

Grossman, Z; Del Torso, S; van Esso, D; Ehrich, J H H; Altorjai, P; Mazur, A; Wyder, C; Neves, A M; Dornbusch, H J; Jaeger Roman, E; Santucci, A; Hadjipanayis, A

2016-11-01

There is limited data on the use and functionality level of electronic health records (EHRs) supporting primary child health care in Europe. Our objective was to determine European primary child healthcare providers' use of EHRs, and functionality level of the systems used. European primary care paediatricians, paediatric subspecialists and family doctors were invited by European Academy of Paediatrics Research in Ambulatory Setting Network (EAPRASnet) country coordinators to complete a web-based survey on the use of EHRs and the systems' functionalities. Binomial logistic analysis has been used to evaluate the effect of specialty and type of practice on the use of EHRs. The survey was completed by 679 child primary healthcare providers (response rate 53%). Five hundred and fifty four responses coming from 10 predominant countries were taken for further analysis. EHR use by respondents varied widely between countries, all electronic type use ranging between 7% and 97%. There was no significant difference in EHR use between group practice and solo practitioners, or between family doctors and primary care paediatricians. History and physical examination can be properly recorded by respondents in most countries. However, growth chart plotting capacity in some countries ranges between 22% and 50%. Vaccination recording capacity varies between 50% and 100%, and data exchange capacity with immunization databases is mostly limited, ranging between 0% and 54%. There is marked heterogeneity in the use and functionalities of EHRs used among child primary child healthcare providers in Europe. More importantly, lack of critical paediatric supportive functionalities like growth tracking and vaccination status has been documented in some countries. There is a need to explore the reasons for these findings, and to develop a cross European paediatric EHR standards. © 2016 John Wiley & Sons Ltd.
Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use.

PubMed

Nelson, Karin M; Helfrich, Christian; Sun, Haili; Hebert, Paul L; Liu, Chuan-Fen; Dolan, Emily; Taylor, Leslie; Wong, Edwin; Maynard, Charles; Hernandez, Susan E; Sanders, William; Randall, Ian; Curtis, Idamay; Schectman, Gordon; Stark, Richard; Fihn, Stephan D

2014-08-01

In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation. To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care. Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001). The extent of PCMH implementation, as measured by the Pi2, was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.
Malignant hypertension: a preventable emergency.

PubMed

van der Merwe, Walter; van der Merwe, Veronica

2013-08-16

The Waitemata Hypertension Clinic Database 2009-2012 (Auckland, New Zealand) was searched for patients meeting the definition of Malignant Hypertension. Eighteen of 565 patients met the criteria. All patients had essential hypertension which was either undiagnosed, untreated or undertreated. Most cases responded satisfactorily to standard drug therapy, but a number were left with significant chronic kidney disease. Malignant hypertension is a life-threatening disease which should be entirely preventable with regular blood pressure checks in primary care.
Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study.

PubMed

Hincapié, Cesar A; Tomlinson, George A; Côté, Pierre; Rampersaud, Y Raja; Jadad, Alejandro R; Cassidy, J David

2017-10-16

Chiropractic care is popular for low back pain, but may increase the risk for acute lumbar disc herniation (LDH). Low back pain is a common early (prodromal) symptom of LDH and commonly precedes LDH diagnosis. Our objective was to investigate the association between chiropractic care and acute LDH with early surgical intervention, and contrast this with the association between primary care physician (PCP) care and acute LDH with early surgery. Using a self-controlled case series design and population-based healthcare databases in Ontario, Canada, we investigated all adults with acute LDH requiring emergency department (ED) visit and early surgical intervention from April 1994 to December 2004. The relative incidence of acute LDH with early surgery in exposed periods after chiropractic visits relative to unexposed periods was estimated within individuals, and compared with the relative incidence of acute LDH with early surgery following PCP visits. 195 cases of acute LDH with early surgery (within 8 weeks) were identified in a population of more than 100 million person-years. Strong positive associations were found between acute LDH and both chiropractic and PCP visits. The risk for acute LDH with early surgery associated with chiropractic visits was no higher than the risk associated with PCP visits. Both chiropractic and primary medical care were associated with an increased risk for acute LDH requiring ED visit and early surgery. Our analysis suggests that patients with prodromal back pain from a developing disc herniation likely seek healthcare from both chiropractors and PCPs before full clinical expression of acute LDH. We found no evidence of excess risk for acute LDH with early surgery associated with chiropractic compared with primary medical care.
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
Testing the effects of brief intervention in primary care for problem drug use in a randomized controlled trial: rationale, design, and methods.

PubMed

Krupski, Antoinette; Joesch, Jutta M; Dunn, Chris; Donovan, Dennis; Bumgardner, Kristin; Lord, Sarah Peregrine; Ries, Richard; Roy-Byrne, Peter

2012-12-14

A substantial body of research has established the effectiveness of brief interventions for problem alcohol use. Following these studies, national dissemination projects of screening, brief intervention (BI), and referral to treatment (SBIRT) for alcohol and drugs have been implemented on a widespread scale in multiple states despite little existing evidence for the impact of BI on drug use for non-treatment seekers. This article describes the design of a study testing the impact of SBIRT on individuals with drug problems, its contributions to the existing literature, and its potential to inform drug policy. The study is a randomized controlled trial of an SBIRT intervention carried out in a primary care setting within a safety net system of care. Approximately 1,000 individuals presenting for scheduled medical care at one of seven designated primary care clinics who endorse problematic drug use when screened are randomized in a 1:1 ratio to BI versus enhanced care as usual (ECAU). Individuals in both groups are reassessed at 3, 6, 9, and 12 months after baseline. Self-reported drug use and other psychosocial measures collected at each data point are supplemented by urine analysis and public health-related data from administrative databases. This study will contribute to the existing literature by providing evidence for the impact of BI on problem drug use based on a broad range of measures including self-reported drug use, urine analysis, admission to drug abuse treatment, and changes in utilization and costs of health care services, arrests, and death with the intent of informing policy and program planning for problem drug use at the local, state, and national levels. ClinicalTrials.gov NCT00877331.
Who Treats Patients with Diabetes and Compensated Cirrhosis

PubMed Central

Barritt IV, A. Sidney; Weinberger, Morris; Paul, John E.; Fried, Bruce; Trogdon, Justin G.

2016-01-01

Background Increasingly, patients with multiple chronic conditions are being managed in patient-centered medical homes (PCMH) that coordinate primary and specialty care. However, little is known about the types of providers treating complex patients with diabetes and compensated cirrhosis. Objective We examined the mix of physician specialties who see patients dually-diagnosed with diabetes and compensated cirrhosis. Design Retrospective cross-sectional study using 2000–2013 MarketScan® Commercial Claims and Encounters and Medicare Supplemental Databases. Patients We identified 22,516 adults (≥ 18 years) dually-diagnosed with diabetes and compensated cirrhosis. Patients with decompensated cirrhosis, HIV/AIDS, or liver transplantation prior to dual diagnosis were excluded. Main Measures Physician mix categories: patients were assigned to one of four physician mix categories: primary care physicians (PCP) with no gastroenterologists (GI) or endocrinologists (ENDO); GI/ENDO with no PCP; PCP and GI/ENDO; and neither PCP nor GI/ENDO. Health care utilization: annual physician visits and health care expenditures were assessed by four physician mix categories. Key Results Throughout the 14 years of study, 92% of patients visited PCPs (54% with GI/ENDO and 39% with no GI/ENDO). The percentage who visited PCPs without GI/ENDO decreased 22% (from 63% to 49%), while patients who also visited GI/ENDO increased 71% (from 25% to 42%). Conclusions This is the first large nationally representative study to document the types of physicians seen by patients dually-diagnosed with diabetes and cirrhosis. A large proportion of these complex patients only visited PCPs, but there was a trend toward greater specialty care. The trend toward co-management by both PCPs and GI/ENDOs suggests that PCMH initiatives will be important for these complex patients. Documenting patterns of primary and specialty care is the first step toward improved care coordination. PMID:27783702
Two decades of change in European general practice service profiles: conditions associated with the developments in 28 countries between 1993 and 2012.

PubMed

Schäfer, Willemijn L A; Boerma, Wienke G W; Spreeuwenberg, Peter; Schellevis, François G; Groenewegen, Peter P

2016-01-01

Evidence regarding the benefits of strong primary care has influenced health policy and practice. This study focuses on changes in the breadth of services provided by general practitioners (GPs) in Europe between 1993 and 2012 and offers possible explanations for these changes. Data on the breadth of service profiles were used from two cross-sectional surveys in 28 countries: the 1993 European GP Task Profile study (6321 GPs) and the 2012 QUALICOPC study (6044 GPs). GPs' involvement in four areas of clinical activity (first contact care, treatment of diseases, medical procedures, and prevention) was established using ecometric analyses. The changes were measured by the relative increase in the breadth of service profiles. Associations between changes and national-level conditions were examined though regression analyses. Data on the national conditions were used from various other public databases including the World Databank and the PHAMEU (Primary Health care Activity Monitor) database. A total of 28 European countries. GPs. Changes in the breadth of GP service profiles. A general trend of increased involvement of European GPs in treatment of diseases and decreased involvement in preventive activities was observed. Conditions at the national level were associated with changes in the involvement of GPs in first contact care, treatment of diseases and, to a limited extent, prevention. Especially in countries with stronger growth of health care expenditures between 1993 and 2012 the service profiles have expanded. In countries where family values are more dominant the breadth in service profiles decreased. A stronger professional status of GPs was positively associated with the change in first contact care. GPs in former communist countries and Turkey have increased their involvement in the provision of services. Developments in Western Europe were less evident. The developments in the service profiles could only to a very limited extent be explained by national conditions. A main driver of reform seems to be the changes in health care expenditure, which may indicate a notion of urgency because there may be a pressure to curb the rising expenditures. Broad GP service profiles are an indicator of strong primary care in a country. It is expected that developments in the breadth of GP service profiles are influenced by various national conditions related to the urgency to reform, politics, and means. Between 1993 and 2012 the involvement of GPs in European countries in treatment of diseases increased and their involvement preventive activities decreased. The national conditions were found to be associated with changes in GPs' involvement as first contact of care, treatment of diseases, and, to a limited extent, prevention. More specifically, in countries with a stronger growth in health care expenditures, service profiles of European GPs have expanded more in the past decades.
A concept for a visual computer interface to make error taxonomies useful at the point of primary care.

PubMed

Singh, Ranjit; Pace, Wilson; Singh, Sonjoy; Singh, Ashok; Singh, Gurdev

2007-01-01

Evidence suggests that the quality of care delivered by the healthcare industry currently falls far short of its capabilities. Whilst most patient safety and quality improvement work to date has focused on inpatient settings, some estimates suggest that outpatient settings are equally important, with up to 200,000 avoidable deaths annually in the United States of America (USA) alone. There is currently a need for improved error reporting and taxonomy systems that are useful at the point of care. This provides an opportunity to harness the benefits of computer visualisation to help structure and illustrate the 'stories' behind errors. In this paper we present a concept for a visual taxonomy of errors, based on visual models of the healthcare system at both macrosystem and microsystem levels (previously published in this journal), and describe how this could be used to create a visual database of errors. In an alphatest in a US context, we were able to code a sample of 20 errors from an existing error database using the visual taxonomy. The approach is designed to capture and disseminate patient safety information in an unambiguous format that is useful to all members of the healthcare team (including the patient) at the point of care as well as at the policy-making level.
Critical illness-related corticosteroid insufficiency (CIRCI): a narrative review from a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM).

PubMed

Annane, Djillali; Pastores, Stephen M; Arlt, Wiebke; Balk, Robert A; Beishuizen, Albertus; Briegel, Josef; Carcillo, Joseph; Christ-Crain, Mirjam; Cooper, Mark S; Marik, Paul E; Meduri, Gianfranco Umberto; Olsen, Keith M; Rochwerg, Bram; Rodgers, Sophia C; Russell, James A; Van den Berghe, Greet

2017-12-01

To provide a narrative review of the latest concepts and understanding of the pathophysiology of critical illness-related corticosteroid insufficiency (CIRCI). A multispecialty task force of international experts in critical care medicine and endocrinology and members of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). Medline, Database of Abstracts of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews. Three major pathophysiologic events were considered to constitute CIRCI: dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, altered cortisol metabolism, and tissue resistance to glucocorticoids. The dysregulation of the HPA axis is complex, involving multidirectional crosstalk between the CRH/ACTH pathways, autonomic nervous system, vasopressinergic system, and immune system. Recent studies have demonstrated that plasma clearance of cortisol is markedly reduced during critical illness, explained by suppressed expression and activity of the primary cortisol-metabolizing enzymes in the liver and kidney. Despite the elevated cortisol levels during critical illness, tissue resistance to glucocorticoids is believed to occur due to insufficient glucocorticoid alpha-mediated anti-inflammatory activity. Novel insights into the pathophysiology of CIRCI add to the limitations of the current diagnostic tools to identify at-risk patients and may also impact how corticosteroids are used in patients with CIRCI.
Barriers to Primary Care Clinician Adherence to Clinical Guidelines for the Management of Low Back Pain: A Systematic Review and Metasynthesis of Qualitative Studies.

PubMed

Slade, Susan C; Kent, Peter; Patel, Shilpa; Bucknall, Tracey; Buchbinder, Rachelle

2016-09-01

Despite the availability of evidence-based guidelines for the management of low back pain (LBP) that contain consistent messages, large evidence-practice gaps in primary care remain. To perform a systematic review and metasynthesis of qualitative studies that have explored primary care clinicians' perceptions and beliefs about guidelines for LBP, including perceived enablers and barriers to guideline adherence. Studies investigating perceptions and beliefs about LBP guidelines were included if participants were primary care clinicians and qualitative methods had been used for both data collection and analysis. We searched major databases up to July 2014. Pairs of reviewers independently screened titles and abstracts, extracted data, appraised method quality using the CASP checklist, conducted thematic analysis, and synthesized the results in narrative format. Seventeen studies, with a total of 705 participants, were included. We identified 3 key emergent themes and 8 subthemes: (1) guideline implementation and adherence beliefs and perceptions; (2) maintaining the patient-clinician relationship with imaging referrals; and (3) barriers to guideline implementation. Clinicians believed that guidelines were categorical, prescriptive, and constrained professional practice; however, popular clinical practices superseded the guidelines. Imaging referrals were used to manage consultations and to obtain definitive diagnoses. Clinicians' perceptions reflected a lack of content knowledge and understanding of how guidelines are developed. Addressing misconceptions and other barriers to uptake of evidence-based guidelines for managing LBP is needed to improve knowledge transfer and close the evidence-practice gap in the treatment of this common condition.
Unintended consequences of eliminating Medicare payments for consultations1

PubMed Central

Song, Zirui; Ayanian, John Z.; Wallace, Jacob; He, Yulei; Gibson, Teresa B.; Chernew, Michael E.

2013-01-01

Background Prior to 2010, Medicare payments for consultations (commonly billed by specialists) were substantially higher than for office visits of similar complexity (commonly billed by primary care physicians). In January 2010, Medicare eliminated consultation payments from the Part B Physician Fee Schedule and increased fees for office visits. This change was intended to be budget neutral and to decrease payments to specialists while increasing payments to primary care physicians. We assessed the impact of this policy on spending, volume, and complexity for outpatient office encounters in 2010. Methods We examined 2007–2010 outpatient claims for 2,247,810 Medicare beneficiaries with Medicare Supplemental (Medigap) coverage through large employers in the Thomson Reuters MarketScan Database. We used segmented regression analysis to study changes in spending, volume, and complexity of office encounters adjusted for age, sex, health status, secular trends, seasonality, and hospital referral region. Results “New” office visits largely replaced consultations in 2010. An average of $10.20 (6.5 percent) more was spent per beneficiary per quarter on physician encounters after the policy. The total volume of physician encounters did not change significantly. The increase in spending was largely explained by higher office visit fees from the policy and a shift toward higher complexity visits to both specialists and primary care physicians. Conclusions The elimination of consultations led to a net increase in spending on visits to both primary care physicians and specialists. Higher prices, partially due to the subjectivity of codes in the physician fee schedule, explained the spending increase, rather than higher volumes. PMID:23336095
70,489 primary care encounters: retrospective analysis of morbidity at a primary care centre in Ireland.

PubMed

Molony, D; Beame, C; Behan, W; Crowley, J; Dennehy, T; Quinlan, M; Cullen, W

2016-11-01

While considerable changes are happening in primary care in Ireland and considerable potential exists in intelligence derived from practice-based data to inform these changes, relatively few large-scale general morbidity surveys have been published. To examine the most common reasons why people attend primary care, specifically 'reasons for encounter' (RFEs) among the general practice population and among specific demographic groups (i.e., young children and older adults). We retrospectively examined clinical encounters (which had a diagnostic code) over a 4-year time period. Descriptive analyses were conducted on anonymised data. 70,489 RFEs consultations were recorded (mean 13.53 recorded RFEs per person per annum) and consultations involving multiple RFEs were common. RFE categories for which codes were most commonly recorded were: 'general/unspecified' (31.6 %), 'respiratory' (15.4 %) and 'musculoskeletal' (12.6 %). Most commonly recorded codes were: 'medication renewal' (6.8 %), 'cough' (6.6 %), and 'health maintenance/prevention' (5.8 %). There was considerable variation in the number of RFEs recorded per age group. 6239 RFEs (8.9 %) were recorded by children under 6 years and 15,295 RFEs (21.7 %) were recorded by adults aged over 70. RFEs recorded per calendar month increased consistently through the study period and there was a marked seasonal and temporal variation in the number of RFEs recorded. Practice databases can generate intelligence on morbidity and health service utilisation in the community. Future research to optimise diagnostic coding at a practice level and to promote this activity in a more representative sample of practices is a priority.
Healthcare utilization in general practice before and after psychological treatment: a follow-up data linkage study in primary care.

PubMed

Prins, Marijn A; Verhaak, Peter F M; Smit, Dineke; Verheij, Robert A

2014-09-01

Literature suggests that serious mental health problems increase the use of health services and psychological interventions can reduce this effect. This study investigates whether this effect is also found in primary care patients with less serious mental health problems. Routine electronic health records (EHR) from a representative sample of 128 general practices were linked to patient files from 150 primary care psychologists participating in the NIVEL Primary Care Database, using a trusted third party. Data were linked using the date of birth, gender, and postcode. This yielded 503 unique data pairs that were listed in one of the participating GP practices in 2008-2010, for people who had psychological treatment from a psychologist that ended in 2009. The number of contacts, health problems presented, and prescribed medication in general practice were analysed before and after the psychological treatment. Nearly all 503 patients consulted their GP during the six months preceding the psychological treatment (90.9%) and also in the six months after this treatment had ended (83.7%). The frequency of contacts was significantly higher before than after the psychological treatment (6.1 vs. 4.8). Fewer patients contacted their GPs specifically for psychological or social problems (46.3% vs. 38.8%) and fewer patients had anxiolytic drug prescriptions (15.5% vs. 7.6%) after psychological treatment. After psychological treatment, patients contact their GPs less often and present fewer psychological or social problems. Although contact rates seem to decrease, clients of psychologists are still frequent GP attenders.

Effectiveness and cost effectiveness of counselling in primary care.

PubMed

Rowland, N; Bower, P; Mellor, C; Heywood, P; Godfrey, C

2001-01-01

There is wide clinician and patient support for counselling in primary care, particularly in the UK. This review examines the effectiveness and cost effectiveness of counselling for psychological and psychosocial problems in the primary care setting. To assess the effects of counselling in primary care by reviewing cost and outcome data for patients with psychological and psychosocial problems considered suitable for counselling. The 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. Contact was made with subject experts and CCDAN members. Randomised and controlled patient preference trials comparing counselling in primary care with usual general practitioner care for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of April 1998 were included in the review. Trials were independently assessed by at least two reviewers for appropriateness of inclusion and methdological quality. Four trials, involving 678 participants, of whom 487 were followed up, were included. Data for psychological symptom levels (four trials) were pooled statistically. Patients receiving counselling had significantly better psychological symptom levels post intervention than patients receiving usual general practitioner care (standardised mean difference -0.30, 95% CI, (-0.49 to - 0.11). The effect remained statistically significant when the results from studies with less rigorous methodology were excluded in a sensitivity analysis. Patients who received counselling tended to be more satisfied with their treatment (three trials). Health service utilisation data were reported in all trials reviewed, but only one trial undertook a cost analysis. No clear cost advantage was associated with either counselling or usual general practice care. Patients who received counselling were more likely to have improved psychological symptom levels than those who did not receive counselling. Levels of satisfaction with counselling were high. There is limited information about the cost effectiveness of counselling, with one study reporting no clear cost advantage with either counselling or general practice care. The four trials included in this review were all pragmatic trials of counselling in primary care in the UK, which reflect the reality of clinical provision in this context. There were methdological weaknesses identified in the studies, which should be taken into account when considering the results. The evidence base will be extended by trials of counselling which are nearing completion.
Full-text publication rate of abstracts presented at the Japan Primary Care Association Annual Meetings (2010-2012): a retrospective observational study.

PubMed

Komagamine, Junpei; Yabuki, Taku

2018-06-22

To determine the publication rate of abstracts presented at the Japan Primary Care Association Annual Meetings and the factors associated with publication. A retrospective observational study. All abstracts presented at the Japan Primary Care Association Annual Meetings (2010-2012). Publication rates were determined by searching the MEDLINE database for full-text articles published by September 2017. Data on presentation format (oral vs poster), affiliation of the first author, number of authors, number of involved institutions, journal of publication and publication date were abstracted. Of the 1003 abstracts evaluated, 38 (3.8%, 95% CI 2.6% to 5.0%) were subsequently published in peer-reviewed journals indexed in the MEDLINE database. The median time to publication was 15.5 months (IQR, 9.3-29.3 months). More than 95% of published abstracts were published within 4 years. The publications appeared in 23 different journals (21 English-language journals and two Japanese-language journals). Based on univariate analysis using binary logistic regression, publication was more frequent for oral presentations (7.3%vs2.0% for poster presentations; OR 3.91,95% CI 1.98 to 7.75), and for first authors affiliated with university-associated institutions (6.4%vs2.4% for first authors affiliated with non-university-associated institutions; OR 2.75,95% CI 1.42 to 5.30). Based on multivariate analysis, oral presentation and first author affiliation with a university-associated institution were still the only independent predictive factors for publication (adjusted OR 3.50(95% CI 1.72 to 7.12) and adjusted OR 2.35(95% CI 1.19 to 4.63), respectively). Even among 151 abstracts presented orally by first authors affiliated with a university-associated institution, only 18 abstracts (11.9%) were subsequently published in peer-reviewed journals. The publication rate of abstracts presented at the Japan Primary Care Association Annual Meetings was extremely low. Further studies are warranted to investigate the barriers to publication among investigators who participate in conferences where the publication rate is extremely low. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Atrial fibrillation: stroke prevention in focus.

PubMed

Ferguson, Caleb; Inglis, Sally C; Newton, Phillip J; Middleton, Sandy; Macdonald, Peter S; Davidson, Patricia M

2014-05-01

Atrial fibrillation (AF) is a common arrhythmia and a risk factor for stroke and other, adverse events. Internationally there have been recent advancements in the therapies available for, stroke prevention in AF. Nurses will care for individuals with AF across a variety of primary and acute, care settings and should be familiar with evidence based therapies. This paper provides a review of the epidemiology of AF and stroke, stroke and bleeding risk, assessment tools and evidence based treatments for the prevention of stroke in AF including the use of, novel anti-thrombin agents. A review of key databases was conducted from 2002 to 2012 using the key search terms 'atrial, fibrillation' 'anticoagulation' 'risk assessment' and 'clinical management'. The following electronic, databases were searched: CINAHL, Medline, Scopus, the Cochrane Library and Google Scholar., Reference lists were manually hand searched. Key clinical guidelines from National Institute for, Clinical Excellence (NICE, UK), American Heart Association (AHA, USA), American College of Cardiology, (ACC, USA) and the European Society of Cardiology (ESC) and key government policy documents were, also included. Articles were included in the review if they addressed nursing management with a focus, on Australia. Many treatment options exist for AF. Best practice guidelines make a variety of, recommendations which include cardioversion, ablation, pulmonary vein isolation, pharmacological, agents for rate or rhythm control approaches, and antithrombotic therapy (including anticoagulation, and antiplatelet therapy). Treatment should be patient centred and individualised based upon, persistency of the rhythm, causal nature, risk and co-morbid conditions. AF is a common and burdensome condition where treatment is complex and not without, risk. Nurses will encounter individuals with AF across a variety of primary and acute care areas, understanding the risk of AF and appropriate therapies is important across all care settings. Treatment, must be individually tailored to the needs of the patient and balanced with the best available evidence. Copyright © 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.
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.
Development of a pseudo/anonymised primary care research database: Proof-of-concept study.

PubMed

MacRury, Sandra; Finlayson, Jim; Hussey-Wilson, Susan; Holden, Samantha

2016-06-01

General practice records present a comprehensive source of data that could form a variety of anonymised or pseudonymised research databases to aid identification of potential research participants regardless of location. A proof-of-concept study was undertaken to extract data from general practice systems in 15 practices across the region to form pseudo and anonymised research data sets. Two feasibility studies and a disease surveillance study compared numbers of potential study participants and accuracy of disease prevalence, respectively. There was a marked reduction in screening time and increase in numbers of potential study participants identified with the research repository compared with conventional methods. Accurate disease prevalence was established and enhanced with the addition of selective text mining. This study confirms the potential for development of national anonymised research database from general practice records in addition to improving data collection for local or national audits and epidemiological projects. © The Author(s) 2014.
Preconception healthcare delivery at a population level: construction of public health models of preconception care.

PubMed

Shannon, Geordan D; Alberg, Corinna; Nacul, Luis; Pashayan, Nora

2014-08-01

A key challenge of preconception healthcare is identifying how it can best be delivered at a population level. To review current strategies of preconception healthcare, explore methods of preconception healthcare delivery, and develop public health models which reflect different preconception healthcare pathways. Preconception care strategies, programmes and evaluations were identified through a review of Medline and Embase databases. Search terms included: preconception, pre-pregnancy, intervention, primary care, healthcare, model, delivery, program, prevention, trial, effectiveness, congenital disorders OR abnormalities, evaluation, assessment, impact. Inclusion criteria for review articles were: (1) English, (2) human subjects, (3) women of childbearing age, (4) 1980–current data, (5) all countries, (6) both high risk and universal approaches, (7) guidelines or recommendations, (8) opinion articles, (9) experimental studies. Exclusion criteria were: (1) non-human subjects, (2) non-English, (3) outside of the specified timeframe, (4) articles on male healthcare. The results of the literature review were synthesised into public health models of care: (1) primary care; (2) hospital-based and inter-conception care; (3) specific preconception care clinics; and, (4) community outreach. Fifteen evaluations of preconception care were identified. Community programmes demonstrated a significant impact on substance use, folic acid supplementation, diabetes optimization, and hyperphenylalaninemia. An ideal preconception visits entail risk screening, education, and intervention if indicated. Subsequently, four public health models were developed synthesizing preconception care delivery at a population level. Heterogeneity of risk factors, health systems and strategies of care reflect the lack of consensus about the best way to deliver preconception care. The proposed models aim to reflect differing aspects of preconception healthcare delivery.
Clopidogrel discontinuation after acute coronary syndromes: frequency, predictors and associations with death and myocardial infarction--a hospital registry-primary care linked cohort (MINAP-GPRD).

PubMed

Boggon, Rachael; van Staa, Tjeerd P; Timmis, Adam; Hemingway, Harry; Ray, Kausik K; Begg, Alan; Emmas, Cathy; Fox, Keith A A

2011-10-01

Adherence to evidence-based treatments and its consequences after acute myocardial infarction (MI) are poorly defined. We examined the extent to which clopidogrel treatment initiated in hospital is continued in primary care; the factors predictive of clopidogrel discontinuation and the hazard of death or recurrent MI. We linked the Myocardial Ischaemia National Audit Project registry and the General Practice Research Database to examine adherence to clopidogrel in primary care among patients discharged from hospital after MI (2003-2009). Hospital Episode Statistics and national mortality data were linked, documenting all-cause mortality and non-fatal MI. Of the 7543 linked patients, 4650 were prescribed clopidogrel in primary care within 3 months of discharge. The adjusted odds of still being prescribed clopidogrel at 12 months were similar following non-ST-elevation myocardial infarction (NSTEMI) 53% (95% CI, 51-55) and ST-elevation myocardial infarction (STEMI) 54% (95% CI, 52-56), but contrast with statins: NSTEMI 84% (95% CI, 82-85) and STEMI 89% (95% CI, 87-90). Discontinuation within 12 months was more frequent in older patients [>80 vs. 40-49 years, adjusted hazard ratio (HR) 1.50 (95% CI, 1.15-1.94)] and with bleeding events [HR 1.34 (95% CI, 1.03-1.73)]. 18.15 patients per 100 person-years (95% CI, 16.83-19.58) died or experienced non-fatal MI in the first year following discharge. In patients who discontinued clopidogrel within 12 months, the adjusted HR for death or non-fatal MI was 1.45 (95% CI, 1.22-1.73) compared with untreated patients, and 2.62 (95% CI, 2.17-3.17) compared with patients persisting with clopidogrel treatment. This is the first study to use linked registries to determine persistence of clopidogrel treatment after MI in primary care. It demonstrates that discontinuation is common and associated with adverse outcomes.
Access to primary care for socioeconomically disadvantaged older people in rural areas: a realist review.

PubMed

Ford, John A; Wong, Geoff; Jones, Andy P; Steel, Nick

2016-05-17

The aim of this review is to identify and understand the contexts that effect access to high-quality primary care for socioeconomically disadvantaged older people in rural areas. A realist review. MEDLINE and EMBASE electronic databases and grey literature (from inception to December 2014). Broad inclusion criteria were used to allow articles which were not specific, but might be relevant to the population of interest to be considered. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded for concepts relating to context, mechanism or outcome. An overarching patient pathway was generated and used as the basis to explore contexts, causal mechanisms and outcomes. 162 articles were included. Most were from the USA or the UK, cross-sectional in design and presented subgroup data by age, rurality or deprivation. From these studies, a patient pathway was generated which included 7 steps (problem identified, decision to seek help, actively seek help, obtain appointment, get to appointment, primary care interaction and outcome). Important contexts were stoicism, education status, expectations of ageing, financial resources, understanding the healthcare system, access to suitable transport, capacity within practice, the booking system and experience of healthcare. Prominent causal mechanisms were health literacy, perceived convenience, patient empowerment and responsiveness of the practice. Socioeconomically disadvantaged older people in rural areas face personal, community and healthcare barriers that limit their access to primary care. Initiatives should be targeted at local contextual factors to help individuals recognise problems, feel welcome, navigate the healthcare system, book appointments easily, access appropriate transport and have sufficient time with professional staff to improve their experience of healthcare; all of which will require dedicated primary care resources. 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/
Costs of vitamin D testing and prescribing among children in primary care.

PubMed

Basatemur, Emre; Hunter, Rachael; Horsfall, Laura; Sutcliffe, Alastair; Rait, Greta

2017-10-01

Vitamin D has attracted considerable interest in recent years, with a marked increase in diagnosis of vitamin D deficiency seen among children in clinical practice in the UK. The economic implications of this change in diagnostic behaviour have not been explored. We performed a cohort study to examine longitudinal trends in healthcare expenditure arising from vitamin D testing and prescribing for children in primary care in England, using the electronic healthcare records of 722,525 children aged 0-17 years held in The Health Improvement Network database. Combined costs of vitamin D tests and prescriptions increased from £1647 per 100,000 person-years in 2008 (95% CI, £934 to £3007) to £28,913 per 100,000 person-years in 2014 (95% CI, £26,361 to £31,739). The total cost of vitamin D prescriptions and tests for children in primary care at the national level in England in 2014 was estimated to be £4.31 million (95% CI, £2.96-£6.48 million). There has been a marked increase in healthcare expenditure on vitamin D tests and prescriptions for children in primary care over the past decade. Future research should explore the drivers for this change in diagnostic behaviour and the reasons prompting investigation of vitamin D status in clinical practice. What is Known: • Vitamin D deficiency has attracted considerable interest in recent years, with a marked increase in diagnosis seen in children. • The economic implications of this change in diagnostic behaviour have not been explored. What is New: • There has been a large increase in healthcare expenditure on vitamin D tests and prescriptions for children in primary care in England over the past decade (> 15 fold between 2008 and 2013). • Screening of vitamin D status in children without specific risk factors or clinical features of deficiency may represent avoidable healthcare expenditure.
Rheumatoid factor testing in Spanish primary care: A population-based cohort study including 4.8 million subjects and almost half a million measurements.

PubMed

Morsley, Klara; Miller, Anne; Luqmani, Raashid; Fina-Aviles, Francesc; Javaid, Muhammad Kassim; Edwards, Christopher J; Pinedo-Villanueva, Rafael; Medina, Manuel; Calero, Sebastian; Cooper, Cyrus; Arden, Nigel; Prieto-Alhambra, Daniel

2018-02-26

Rheumatoid factor (RF) testing is used in primary care in the diagnosis of rheumatoid arthritis (RA); however a positive RF may occur without RA. Incorrect use of RF testing may lead to increased costs and delayed diagnoses. The aim was to assess the performance of RF as a test for RA and to estimate the costs associated with its use in a primary care setting. A retrospective cohort study using the Information System for the Development of Research in Primary Care database (contains primary care records and laboratory results of >80% of the Catalonian population, Spain). Participants were patients ≥18 years with ≥1 RF test performed between 01/01/2006 and 31/12/2011, without a pre-existing diagnosis of RA. Outcome measures were an incident diagnosis of RA within 1 year of testing, and the cost of testing per case of RA. 495,434/4,796,498 (10.3%) patients were tested at least once. 107,362 (21.7%) of those tested were sero-positive of which 2768 (2.6%) were diagnosed with RA within 1 year as were 1141/388,072 (0.3%) sero-negative participants. The sensitivity of RF was 70.8% (95% CI 69.4-72.2), specificity 78.7% (78.6-78.8), and positive and negative predictive values 2.6% (2.5-2.7) and 99.7% (99.6-99.7) respectively. Approximately €3,963,472 was spent, with a cost of €1432 per true positive case. Although 10% of patients were tested for RF, most did not have RA. Limiting testing to patients with a higher pre-test probability would significantly reduce the cost of testing. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.
Experiences and shared meaning of teamwork and interprofessional collaboration among health care professionals in primary health care settings: a systematic review.

PubMed

Sangaleti, Carine; Schveitzer, Mariana Cabral; Peduzzi, Marina; Zoboli, Elma Lourdes Campos Pavone; Soares, Cassia Baldini

2017-11-01

During the last decade, teamwork has been addressed under the rationale of interprofessional practice or collaboration, highlighted by the attributes of this practice such as: interdependence of professional actions, focus on user needs, negotiation between professionals, shared decision making, mutual respect and trust among professionals, and acknowledgment of the role and work of the different professional groups. Teamwork and interprofessional collaboration have been pointed out as astrategy for effective organization of health care services as the complexity of healthcare requires integration of knowledge and practices from differente professional groups. This integration has a qualitative dimension that can be identified through the experiences of health professionals and to the meaning they give to teamwork. The objective of this systematic review was to synthesize the best available evidence on the experiences of health professionals regarding teamwork and interprofessional collaboration in primary health care settings. The populations included were all officially regulated health professionals that work in primary health settings: dentistry, medicine, midwifery, nursing, nutrition, occupational therapy, pharmacy, physical education, physiotherapy, psychology, social work and speech therapy. In addition to these professionals, community health workers, nursing assistants, licensed practical nurses and other allied health workers were also included. The phenomena of interest were experiences of health professionals regarding teamwork and interprofessional collaboration in primary health care settings. The context was primary health care settings that included health care centers, health maintenance organizations, integrative medicine practices, integrative health care, family practices, primary care organizations and family medical clinics. National health surgery as a setting was excluded. The qualitative component of the review considered studies that focused on qualitative data including designs such as phenomenology, grounded theory, ethnography, action research and feminist research. A three-step search strategy was utilized. Ten databases were searched for papers published from 1980 to June 2015. Studies published in English, Portuguese and Spanish were considered. Methodological quality was assessed using the Qualitative Assessment and Review Instrument developed by the Joanna Briggs Institute. All included studies received a score of at least 70% the questions in the instrument, 11 studies did not address the influence of the researcher on the research or vice-versa, and six studies did not present a statement locating the researcher culturally or theoretically. Qualitative findings were extracted using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. Qualitative research findings were pooled using a pragmatic meta-aggregative approach and the Joanna Briggs Institute Qualitative Assessment and Review Instrument software. This review included 21 research studies, representing various countries and healthcare settings. There were 223 findings, which were aggregated into 15 categories, and three synthesized findings: CONCLUSIONS: This review shows that health professionals experience teamwork and interprofessional collaboration as a process in primary health care settings; its conditions, consequences (benefits and barriers), and finally shows its determinants. Health providers face enormous ideological, organizational, structural and relational challenges while promoting teamwork and interprofessional collaboration in primary health care settings. This review has identified possible actions that could improve implementation of teamwork and interprofessional collaboration in primary health care.
Functional Status Outperforms Comorbidities as a Predictor of 30-Day Acute Care Readmissions in the Inpatient Rehabilitation Population.

PubMed

Shih, Shirley L; Zafonte, Ross; Bates, David W; Gerrard, Paul; Goldstein, Richard; Mix, Jacqueline; Niewczyk, Paulette; Greysen, S Ryan; Kazis, Lewis; Ryan, Colleen M; Schneider, Jeffrey C

2016-10-01

Functional status is associated with patient outcomes, but is rarely included in hospital readmission risk models. The objective of this study was to determine whether functional status is a better predictor of 30-day acute care readmission than traditionally investigated variables including demographics and comorbidities. Retrospective database analysis between 2002 and 2011. 1158 US inpatient rehabilitation facilities. 4,199,002 inpatient rehabilitation facility admissions comprising patients from 16 impairment groups within the Uniform Data System for Medical Rehabilitation database. Logistic regression models predicting 30-day readmission were developed based on age, gender, comorbidities (Elixhauser comorbidity index, Deyo-Charlson comorbidity index, and Medicare comorbidity tier system), and functional status [Functional Independence Measure (FIM)]. We hypothesized that (1) function-based models would outperform demographic- and comorbidity-based models and (2) the addition of demographic and comorbidity data would not significantly enhance function-based models. For each impairment group, Function Only Models were compared against Demographic-Comorbidity Models and Function Plus Models (Function-Demographic-Comorbidity Models). The primary outcome was 30-day readmission, and the primary measure of model performance was the c-statistic. All-cause 30-day readmission rate from inpatient rehabilitation facilities to acute care hospitals was 9.87%. C-statistics for the Function Only Models were 0.64 to 0.70. For all 16 impairment groups, the Function Only Model demonstrated better c-statistics than the Demographic-Comorbidity Models (c-statistic difference: 0.03-0.12). The best-performing Function Plus Models exhibited negligible improvements in model performance compared to Function Only Models, with c-statistic improvements of only 0.01 to 0.05. Readmissions are currently used as a marker of hospital performance, with recent financial penalties to hospitals for excessive readmissions. Function-based readmission models outperform models based only on demographics and comorbidities. Readmission risk models would benefit from the inclusion of functional status as a primary predictor. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.
National socioeconomic indicators are associated with outcomes after aneurysmal subarachnoid hemorrhage: a hierarchical mixed-effects analysis.

PubMed

Guha, Daipayan; Ibrahim, George M; Kertzer, Joshua D; Macdonald, R Loch

2014-11-01

Although heterogeneity exists in patient outcomes following subarachnoid hemorrhage (SAH) across different centers and countries, it is unclear which factors contribute to such disparities. In this study, the authors performed a post hoc analysis of a large international database to evaluate the association between a country's socioeconomic indicators and patient outcome following aneurysmal SAH. An analysis was performed on a database of 3552 patients enrolled in studies of tirilazad mesylate for aneurysmal SAH from 1991 to 1997, which included 162 neurosurgical centers in North and Central America, Australia, Europe, and Africa. Two primary outcomes were assessed at 3 months after SAH: mortality and Glasgow Outcome Scale (GOS) score. The association between these outcomes, nation-level socioeconomic indicators (percapita gross domestic product [GDP], population-to-neurosurgeon ratio, and health care funding model), and patientlevel covariates were assessed using a hierarchical mixed-effects logistic regression analysis. Multiple previously identified patient-level covariates were significantly associated with increased mortality and worse neurological outcome, including age, intraventricular hemorrhage, and initial neurological grade. Among national-level covariates, higher per-capita GDP (p < 0.05) was associated with both reduced mortality and improved neurological outcome. A higher population-to-neurosurgeon ratio (p < 0.01), as well as fewer neurosurgical centers per population (p < 0.001), was also associated with better neurological outcome (p < 0.01). Health care funding model was not a significant predictor of either primary outcome. Higher per-capita gross GDP and population-to-neurosurgeon ratio were associated with improved outcome after aneurysmal SAH. The former result may speak to the availability of resources, while the latter may be a reflection of better outcomes with centralized care. Although patient clinical and radiographic phenotypes remain the primary predictors of outcome, this study shows that national socioeconomic disparities also explain heterogeneity in outcomes following SAH.
[Management of adult secondary insomnia in primary health care].

PubMed

Cavadas, Luís Filipe; Ribeiro, Lúcia

2011-01-01

Insomnia is the most common sleep disorder in adults, with secondary insomnia being the most prevalent. This sleep disorder is associated with important medical and social consequences. The General Practitioner (GP) plays a key role in the diagnosis of insomnia, which may affect about 69% of their patients in the PHC (Primary Health Care). Recognize the differential diagnosis of secondary insomnia in adults, evaluate and manage these patients in the PHC, appropriately use the treatments available and meet the criteria for referral. Bibliographic search in MEDLINE databases, and evidence based review databases, using the MeSH terms: Primary Health Care, Sleep Disorders, Insomnia, for articles published since January 2000 until July 2009, in English, Portuguese, French and Spanish. Index de Revistas Médicas Portuguesas and scientific societies dedicated to sleep disorders were searched. Mood and anxiety disorders are the main co-morbidities associated with secondary insomnia, being present in 30% to 50% of patients with insomnia. The medical pathology and substance abuse are present respectively in 10% of patients. It is essential a proper clinical history, with a history of sleep, sleep diary and the partner information. There is evidence that the combination of specific pharmacological treatments (benzodiazepines and the benzodiazepine receptor agonists) with the nonpharmacological (cognitive-behavioral therapy) may be useful in secondary insomnia, as co-adjuvant treatment of the underlying disease. There are several treatment options with their indications and adverse effects. The criteria for referral should be defined according to the availability of human resources. Due to the high prevalence and the serious consequences of secondary insomnia in adults, it must be systematically managed by the GP. It is important to know and to use non-pharmacological therapy in GP consultation, because this therapy was shown to be important in treating this type of insomnia. The GP must know the precise indications for pharmacological treatment and criteria for referral.
A mapping review of the literature on UK-focused health and social care databases.

PubMed

Cooper, Chris; Rogers, Morwenna; Bethel, Alison; Briscoe, Simon; Lowe, Jenny

2015-03-01

Bibliographic databases are a day-to-day tool of the researcher: they offer the researcher easy and organised access to knowledge, but how much is actually known about the databases on offer? The focus of this paper is UK health and social care databases. These databases are often small, specialised by topic, and provide a complementary literature to the large, international databases. There is, however, good evidence that these databases are overlooked in systematic reviews, perhaps because little is known about what they can offer. To systematically locate and map, published and unpublished literature on the key UK health and social care bibliographic databases. Systematic searching and mapping. Two hundred and forty-two items were identified which specifically related to the 24 of the 34 databases under review. There is little published or unpublished literature specifically analysing the key UK health and social care databases. Since several UK databases have closed, others are at risk, and some are overlooked in reviews, better information is required to enhance our knowledge. Further research on UK health and social care databases is required. This paper suggests the need to develop the evidence base through a series of case studies on each of the databases. © 2014 The authors. Health Information and Libraries Journal © 2014 Health Libraries Journal.
Electroacupuncture for women with stress urinary incontinence: Protocol for a systematic review and meta-analysis.

PubMed

Huang, Weixin; Li, Xiaohui; Wang, Yuanping; Yan, Xia; Wu, Siping

2017-12-01

Stress urinary incontinence (SUI) is a widespread complaint in the adult women. Electroacupuncture has been widely applied in the treatment of SUI. But its efficacy has not been evaluated scientifically and systematically. Therefore, we provide a protocol of systematic evaluation to assess the effectiveness and safety of electroacupuncture treatment on women with SUI. The retrieved databases include 3 English literature databases, namely PubMed, Embase, and Cochrane Library, and 3 Chinese literature databases, namely Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and Wanfang Database. The randomized controlled trials (RCTs) of the electroacupuncture treatment on women with SUI will be searched in the above-mentioned databases from the time when the respective databases were established to December 2017. The change from baseline in the amount of urine leakage measured by the 1-hour pad test will be accepted as the primary outcomes. We will use RevMan V.5.3 software as well to compute the data synthesis carefully when a meta-analysis is allowed. This study will provide a high-quality synthesis to assess the effectiveness and safety of electroacupuncture treatment on women with SUI. The conclusion of our systematic review will provide evidence to judge whether electroacupuncture is an effective intervention for women with SUI. PROSPERO CRD42017070947.
Risk of incident cardiovascular events amongst individuals with anxiety and depression: A prospective cohort study in the east London primary care database.

PubMed

Mathur, R; Pérez-Pinar, M; Foguet-Boreu, Q; Ayis, S; Ayerbe, L

2016-12-01

It is unknown how risk of myocardial infarction and stroke differ for patients with and without anxiety or depression, and whether this risk can be explained by demographics, medication use, cardiovascular risk factors. The aim of this study is to quantify differences in risk of non-fatal MI or stroke among patients with anxiety or depression. Prospective cohort study examining risk of incident MI and stroke between March 2005 and March 2015 for 524,952 patients aged 30 and over from the east London primary care database for patients with anxiety or depression. Amongst 21,811 individuals with depression at baseline, 1.2% had MI and 0.4% had stroke. Of 22,128 individuals with anxiety at baseline, 1.1% had MI and 0.3% had stroke. Depression was independently associated with both MI and stroke, whereas anxiety was associated with MI only before adjustment for cardiovascular risk factors. Antidepressant use increased risk for MI but not stroke. Mean age at first MI was lower in those with anxiety, while mean age at first stroke was lower in those with depression. The study was limited to patients currently registered in the database and thus we did not have any patients that died during the course of follow-up. Patients with depression have increased risk of cardiovascular events. The finding of no increased cardiovascular risk in those with anxiety after adjusting for cardiovascular risk factors is of clinical importance and highlights that the adequate control of traditional risk factors is the cornerstone of cardiovascular disease prevention. Targeting management of classical cardiovascular risk factors and evaluating the risks of antidepressant prescribing should be prioritized. Copyright © 2016 Elsevier B.V. All rights reserved.
Risk of acute liver injury associated with use of antibiotics. Comparative cohort and nested case-control studies using two primary care databases in Europe.

PubMed

Brauer, Ruth; Douglas, Ian; Garcia Rodriguez, Luis Alberto; Downey, Gerald; Huerta, Consuelo; de Abajo, Francisco; Bate, Andrew; Feudjo Tepie, Maurille; de Groot, Mark C H; Schlienger, Raymond; Reynolds, Robert; Smeeth, Liam; Klungel, Olaf; Ruigómez, Ana

2016-03-01

To assess the impact of varying study designs, exposure and outcome definitions on the risk of acute liver injury (ALI) associated with antibiotic use. The source population comprised of patients registered in two primary care databases, in the UK and in Spain. We identified a cohort consisting of new users of antibiotics during the study period (2004-2009) and non-users during the study period or in the previous year. Cases with ALI were identified within this cohort and classified as definite or probable, based on recorded medical information. The relative risk (RR) of ALI associated with antibiotic use was computed using Poisson regression. For the nested case-control analyses, up to five controls were matched to each case by age, sex, date and practice (in CPRD) and odds ratios (OR) were computed with conditional logistic regression. The age, sex and year adjusted RRs of definite ALI in the current antibiotic use periods was 10.04 (95% CI: 6.97-14.47) in CPRD and 5.76 (95% CI: 3.46-9.59) in BIFAP. In the case-control analyses adjusting for life-style, comorbidities and use of medications, the OR of ALI for current users of antibiotics was and 5.7 (95% CI: 3.46-9.36) in CPRD and 2.6 (95% CI: 1.26-5.37) in BIFAP. Guided by a common protocol, both cohort and case-control study designs found an increased risk of ALI associated with the use of antibiotics in both databases, independent of the exposure and case definitions used. However, the magnitude of the risk was higher in CPRD compared to BIFAP. Copyright © 2016 John Wiley & Sons, Ltd.
Manual therapy for unsettled, distressed and excessively crying infants: a systematic review and meta-analyses.

PubMed

Carnes, Dawn; Plunkett, Austin; Ellwood, Julie; Miles, Clare

2018-01-24

To conduct a systematic review and meta-analyses to assess the effect of manual therapy interventions for healthy but unsettled, distressed and excessively crying infants and to provide information to help clinicians and parents inform decisions about care. We reviewed published peer-reviewed primary research articles in the last 26 years from nine databases (Medline Ovid, Embase, Web of Science, Physiotherapy Evidence Database, Osteopathic Medicine Digital Repository , Cochrane (all databases), Index of Chiropractic Literature, Open Access Theses and Dissertations and Cumulative Index to Nursing and Allied Health Literature). Our inclusion criteria were: manual therapy (by regulated or registered professionals) of unsettled, distressed and excessively crying infants who were otherwise healthy and treated in a primary care setting. Outcomes of interest were: crying, feeding, sleep, parent-child relations, parent experience/satisfaction and parent-reported global change. Nineteen studies were selected for full review: seven randomised controlled trials, seven case series, three cohort studies, one service evaluation study and one qualitative study.We found moderate strength evidence for the effectiveness of manual therapy on: reduction in crying time (favourable: -1.27 hours per day (95% CI -2.19 to -0.36)), sleep (inconclusive), parent-child relations (inconclusive) and global improvement (no effect). The risk of reported adverse events was low: seven non-serious events per 1000 infants exposed to manual therapy (n=1308) and 110 per 1000 in those not exposed. Some small benefits were found, but whether these are meaningful to parents remains unclear as does the mechanisms of action. Manual therapy appears relatively safe. CRD42016037353. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Manual therapy for unsettled, distressed and excessively crying infants: a systematic review and meta-analyses

PubMed Central

Carnes, Dawn; Plunkett, Austin; Ellwood, Julie; Miles, Clare

2018-01-01

Objective To conduct a systematic review and meta-analyses to assess the effect of manual therapy interventions for healthy but unsettled, distressed and excessively crying infants and to provide information to help clinicians and parents inform decisions about care. Methods We reviewed published peer-reviewed primary research articles in the last 26 years from nine databases (Medline Ovid, Embase, Web of Science, Physiotherapy Evidence Database, Osteopathic Medicine Digital Repository, Cochrane (all databases), Index of Chiropractic Literature, Open Access Theses and Dissertations and Cumulative Index to Nursing and Allied Health Literature). Our inclusion criteria were: manual therapy (by regulated or registered professionals) of unsettled, distressed and excessively crying infants who were otherwise healthy and treated in a primary care setting. Outcomes of interest were: crying, feeding, sleep, parent–child relations, parent experience/satisfaction and parent-reported global change. Results Nineteen studies were selected for full review: seven randomised controlled trials, seven case series, three cohort studies, one service evaluation study and one qualitative study. We found moderate strength evidence for the effectiveness of manual therapy on: reduction in crying time (favourable: −1.27 hours per day (95% CI −2.19 to –0.36)), sleep (inconclusive), parent–child relations (inconclusive) and global improvement (no effect). The risk of reported adverse events was low: seven non-serious events per 1000 infants exposed to manual therapy (n=1308) and 110 per 1000 in those not exposed. Conclusions Some small benefits were found, but whether these are meaningful to parents remains unclear as does the mechanisms of action. Manual therapy appears relatively safe. PROSPERO registration number CRD42016037353. PMID:29371279

Comparing Emergency Department Use Among Medicaid and Commercial Patients Using All-Payer All-Claims Data.

PubMed

Kim, Hyunjee; McConnell, K John; Sun, Benjamin C

2017-08-01

The high rate of emergency department (ED) use by Medicaid patients is not fully understood. The objective of this paper is (1) to provide context for ED service use by comparing Medicaid and commercial patients' differences across ED and non-ED health service use, and (2) to assess the extent to which Medicaid-commercial differences in ED use can be explained by observable factors in administrative data. Statistical decomposition methods were applied to ED, mental health, and inpatient care using 2011-2013 Medicaid and commercial insurance claims from the Oregon All Payer All Claims database. Demographics, comorbidities, health services use, and neighborhood characteristics accounted for 44% of the Medicaid-commercial difference in ED use, compared to 83% for mental health care and 75% for inpatient care. This suggests that relative to mental health and inpatient care, a large portion of ED use cannot be explained by administrative data. Models that further accounted for patient access to different primary care physicians explained an additional 8% of the Medicaid-commercial difference in ED use, suggesting that the quality of primary care may influence ED use. The remaining unexplained difference suggests that appropriately reducing ED use remains a credible target for policy makers, although success may require knowledge about patients' perceptions and behaviors as well as social determinants of health.
Physical rehabilitation interventions for adult patients with critical illness across the continuum of recovery: an overview of systematic reviews protocol.

PubMed

Connolly, Bronwen; O'Neill, Brenda; Salisbury, Lisa; McDowell, Kathryn; Blackwood, Bronagh

2015-09-29

Patients admitted to the intensive care unit with critical illness often experience significant physical impairments, which typically persist for many years following resolution of the original illness. Physical rehabilitation interventions that enhance restoration of physical function have been evaluated across the continuum of recovery following critical illness including within the intensive care unit, following discharge to the ward and beyond hospital discharge. Multiple systematic reviews have been published appraising the expanding evidence investigating these physical rehabilitation interventions, although there appears to be variability in review methodology and quality. We aim to conduct an overview of existing systematic reviews of physical rehabilitation interventions for adult intensive care patients across the continuum of recovery. This protocol has been developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines. We will search the Cochrane Systematic Review Database, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, MEDLINE, Excerpta Medica Database and Cumulative Index to Nursing and Allied Health Literature databases. We will include systematic reviews of randomised controlled trials of adult patients, admitted to the intensive care unit and who have received physical rehabilitation interventions at any time point during their recovery. Data extraction will include systematic review aims and rationale, study types, populations, interventions, comparators, outcomes and quality appraisal method. Primary outcomes of interest will focus on findings reflecting recovery of physical function. Quality of reporting and methodological quality will be appraised using the PRISMA checklist and the Assessment of Multiple Systematic Reviews tool. We anticipate the findings from this novel overview of systematic reviews will contribute to the synthesis and interpretation of existing evidence regarding physical rehabilitation interventions and physical recovery in post-critical illness patients across the continuum of recovery. PROSPERO CRD42015001068.
Improving diabetes care among patients with severe mental illness: A systematic review of the effect of interventions.

PubMed

Grøn, A O; Dalsgaard, E-M; Ribe, A R; Seidu, S; Mora, G; Cebrián-Cuenca, A M; Charles, M

2018-04-27

Individuals with severe mental illness (SMI) who suffer from type 2 diabetes (T2DM) are likely to be sub-optimally treated for their physical condition. This study aimed to review the effect of interventions in this population. A systematic search in five databases was conducted in July 2017. Seven studies on multi-faced interventions were included. These comprised nutrition and exercise counselling, behavioural modelling and increased disease awareness aiming to reduce HbA1c, fasting plasma glucose, body mass index and weight. Non-pharmacologic interventions in individuals with SMI and T2DM could possibly improve measures of diabetes care, although with limited clinical impact. Copyright © 2018 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
The role of Tamang mothers-in-law in promoting breast feeding in Makwanpur District, Nepal.

PubMed

Masvie, Hilde

2006-03-01

to systematically analyse the Nepalise grandmother's own perspective of breast feeding. a qualitative approach was used. Three focus-group discussions and eight semi-structured interviews formed the primary database. All interviews and discussions were tape recorded, and translated transcripts and field notes were analysed. Makwanpur District, rural Nepal. 31 Tamang mothers-in-law living in a household with their son's family, and taking part in child care. the data suggest that the mothers-in-law see themselves as key providers of, and decision-makers in, perinatal care practices. Traditional patterns of promotive and preventive care were identified. contrary to the widespread reports that early breast feeding is delayed in this setting, these grandmothers held colostrum in high regard, used no prelacteals and supported early initiation of breast feeding.
Three parallel information systems for malaria elimination in Swaziland, 2010-2015: are the numbers the same?

PubMed

Zulu, Z; Kunene, S; Mkhonta, N; Owiti, P; Sikhondze, W; Mhlanga, M; Simelane, Z; Geoffroy, E; Zachariah, R

2018-04-25

Background: To be able to eliminate malaria, accurate, timely reporting and tracking of all confirmed malaria cases is crucial. Swaziland, a country in the process of eliminating malaria, has three parallel health information systems. Design: This was a cross-sectional study using country-wide programme data from 2010 to 2015. Methods: The Malaria Surveillance Database System (MSDS) is a comprehensive malaria database, the Immediate Disease Notification System (IDNS) is meant to provide early warning and trigger case investigations to prevent onward malaria transmission and potential epidemics, and the Health Management Information Systems (HMIS) reports on all morbidity at health facility level. Discrepancies were stratified by health facility level and type. Results: Consistent over-reporting of 9-85% was noticed in the HMIS, principally at the primary health care level (clinic and/or health centre). In the IDNS, the discrepancy went from under-reporting (12%) to over-reporting (32%); this was also seen at the primary care level. At the hospital level, there was under-reporting in both the HMIS and IDNS. Conclusions: There are considerable discrepancies in the numbers of confirmed malaria cases in the HMIS and IDNS in Swaziland. This may misrepresent the malaria burden and delay case investigation, predisposing the population to potential epidemics. There is an urgent need to improve data integrity in order to guide and evaluate efforts toward elimination.
Three parallel information systems for malaria elimination in Swaziland, 2010–2015: are the numbers the same?

PubMed Central

Kunene, S.; Mkhonta, N.; Owiti, P.; Sikhondze, W.; Mhlanga, M.; Simelane, Z.; Geoffroy, E.; Zachariah, R.

2018-01-01

Background: To be able to eliminate malaria, accurate, timely reporting and tracking of all confirmed malaria cases is crucial. Swaziland, a country in the process of eliminating malaria, has three parallel health information systems. Design: This was a cross-sectional study using country-wide programme data from 2010 to 2015. Methods: The Malaria Surveillance Database System (MSDS) is a comprehensive malaria database, the Immediate Disease Notification System (IDNS) is meant to provide early warning and trigger case investigations to prevent onward malaria transmission and potential epidemics, and the Health Management Information Systems (HMIS) reports on all morbidity at health facility level. Discrepancies were stratified by health facility level and type. Results: Consistent over-reporting of 9–85% was noticed in the HMIS, principally at the primary health care level (clinic and/or health centre). In the IDNS, the discrepancy went from under-reporting (12%) to over-reporting (32%); this was also seen at the primary care level. At the hospital level, there was under-reporting in both the HMIS and IDNS. Conclusions: There are considerable discrepancies in the numbers of confirmed malaria cases in the HMIS and IDNS in Swaziland. This may misrepresent the malaria burden and delay case investigation, predisposing the population to potential epidemics. There is an urgent need to improve data integrity in order to guide and evaluate efforts toward elimination. PMID:29713588
The risk of Clostridium difficile infection in patients with pernicious anaemia: a retrospective cohort study using primary care database.

PubMed

Othman, Fatmah; Crooks, Colin J; Card, Timothy R

2017-11-01

Studies have found an association between proton pump inhibitor (PPI) use and Clostridium difficile infection. The purpose of this study was to determine whether the mechanism by which PPIs induce an increased risk of C. difficile infection is supported by the same mechanism acting in another cause of achlorhydria, pernicious anaemia. Using a database of anonymised primary care records between 1990 and 2013, we selected exposed patients with a diagnosis of pernicious anaemia treated with vitamin B12 therapy. Each exposed patient was matched by age, gender and general practice to up to 10 controls. Cox regression analysis was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for C. difficile infection with pernicious anaemia, adjusted for potential confounders. We identified 45,467 exposed patients matched to 449,635 controls. The crude incidence rate of C. difficile infection was 1.85/1000 person-years for the exposed cohort and 1.09/1000 person-years for controls. Patients with pernicious anaemia had a greater risk of C. difficile infection than the controls (adjusted HR 1.57, 95% CI 1.40-1.76). Pernicious anaemia patients have an increased risk of C. difficile infection. This supports the theory that severe achlorhydria is the mechanism that increases the risk of C. difficile infection in long-term PPI users.
The risk of Clostridium difficile infection in patients with pernicious anaemia: a retrospective cohort study using primary care database

PubMed Central

Crooks, Colin J; Card, Timothy R

2017-01-01

Background Studies have found an association between proton pump inhibitor (PPI) use and Clostridium difficile infection. The purpose of this study was to determine whether the mechanism by which PPIs induce an increased risk of C. difficile infection is supported by the same mechanism acting in another cause of achlorhydria, pernicious anaemia. Methods Using a database of anonymised primary care records between 1990 and 2013, we selected exposed patients with a diagnosis of pernicious anaemia treated with vitamin B12 therapy. Each exposed patient was matched by age, gender and general practice to up to 10 controls. Cox regression analysis was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for C. difficile infection with pernicious anaemia, adjusted for potential confounders. Results We identified 45,467 exposed patients matched to 449,635 controls. The crude incidence rate of C. difficile infection was 1.85/1000 person-years for the exposed cohort and 1.09/1000 person-years for controls. Patients with pernicious anaemia had a greater risk of C. difficile infection than the controls (adjusted HR 1.57, 95% CI 1.40–1.76). Conclusions Pernicious anaemia patients have an increased risk of C. difficile infection. This supports the theory that severe achlorhydria is the mechanism that increases the risk of C. difficile infection in long-term PPI users. PMID:29163961
The degree of integration of non-dispensing pharmacists in primary care practice and the impact on health outcomes: A systematic review.

PubMed

Hazen, Ankie C M; de Bont, Antoinette A; Boelman, Lia; Zwart, Dorien L M; de Gier, Johan J; de Wit, Niek J; Bouvy, Marcel L

2018-03-01

A non-dispensing pharmacist conducts clinical pharmacy services aimed at optimizing patients individual pharmacotherapy. Embedding a non-dispensing pharmacist in primary care practice enables collaboration, probably enhancing patient care. The degree of integration of non-dispensing pharmacists into multidisciplinary health care teams varies strongly between settings. The degree of integration may be a determinant for its success. This study investigates how the degree of integration of a non-dispensing pharmacist impacts medication related health outcomes in primary care. In this literature review we searched two electronic databases and the reference list of published literature reviews for studies about clinical pharmacy services performed by non-dispensing pharmacists physically co-located in primary care practice. We assessed the degree of integration via key dimensions of integration based on the conceptual framework of Walshe and Smith. We included English language studies of any design that had a control group or baseline comparison published from 1966 to June 2016. Descriptive statistics were used to correlate the degree of integration to health outcomes. The analysis was stratified for disease-specific and patient-centered clinical pharmacy services. Eighty-nine health outcomes in 60 comparative studies contributed to the analysis. The accumulated evidence from these studies shows no impact of the degree of integration of non-dispensing pharmacists on health outcomes. For disease specific clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 75%, 63% and 59%. For patient-centered clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 55%, 57% and 70%. Full integration adds value to patient-centered clinical pharmacy services, but not to disease-specific clinical pharmacy services. To obtain maximum benefits of clinical pharmacy services for patients with multiple medications and comorbidities, full integration of non-dispensing pharmacists should be promoted. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.
Community characteristics affecting emergency department use by Medicaid enrollees.

PubMed

Lowe, Robert A; Fu, Rongwei; Ong, Emerson T; McGinnis, Paul B; Fagnan, Lyle J; Vuckovic, Nancy; Gallia, Charles

2009-01-01

In seeking to identify modifiable, system-level factors affecting emergency department (ED) use, we used a statewide Medicaid database to study community variation in ED use and ascertain community characteristics associated with higher use. This historical cohort study used administrative data from July 1, 2003 to December 31, 2004. Residence ZIP codes were used to assign all 555,219 Medicaid enrollees to 130 primary care service areas (PCSAs). PCSA characteristics studied included rural/urban status, presence of hospital(s), driving time to hospital, and several measures of primary care capacity. Statistical analyses used a 2-stage model. In the first stage (enrollee level), ED utilization rates adjusted for enrollee demographics and medical conditions were calculated for each PCSA. In the second stage (community level), a mixed effects linear model was used to determine the association between PCSA characteristics and ED use. ED utilization rates varied more than 20-fold among the PCSAs. Compared with PCSAs with primary care capacity less than need, PCSAs with capacity 1 to 2 times the need had 0.12 (95% CI: -0.044, -0.20) fewer ED visits/person/yr. Compared with PCSAs with the nearest hospital accessible within 10 minutes, PCSAs with the nearest hospital >30 minutes' drive had 0.26 (95% CI: -0.38, -0.13) fewer ED visits/person/yr. Within this Medicaid population, ED utilization was determined not only by patient characteristics but by community characteristics. Better understanding of system-level factors affecting ED use can enable communities to improve their health care delivery systems-augmenting access to care and reducing reliance on EDs.
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.
Are brief interventions to increase physical activity cost-effective? A systematic review

PubMed Central

GC, Vijay; Suhrcke, Marc; Hardeman, Wendy; Sutton, Stephen

2016-01-01

Objective To determine whether brief interventions promoting physical activity are cost-effective in primary care or community settings. Design Systematic review of economic evaluations. Methods and data sources We searched MEDLINE, EMBASE, PsycINFO, CINAHL, EconLit, SPORTDiscus, PEDro, the Cochrane library, National Health Service Economic Evaluation Database and the Cost-Effectiveness Analysis Registry up to 20 August 2014. Web of Knowledge was used for cross-reference search. We included studies investigating the cost-effectiveness of brief interventions, as defined by National Institute for Health and Care Excellence, promoting physical activity in primary care or the community. Methodological quality was assessed using Drummond's checklist for economic evaluations. Data were extracted from individual studies fulfilling selection criteria using a standardised pro forma. Comparisons of cost-effectiveness and cost-utility ratios were made between studies. Results Of 1840 identified publications, 13 studies fulfilled the inclusion criteria describing 14 brief interventions. Studies varied widely in the methods used, such as the perspective of economic analysis, intervention effects and outcome measures. The incremental cost of moving an inactive person to an active state, estimated for eight studies, ranged from £96 to £986. The cost-utility was estimated in nine studies compared with usual care and varied from £57 to £14 002 per quality-adjusted life year; dominant to £6500 per disability-adjusted life year; and £15 873 per life years gained. Conclusions Brief interventions promoting physical activity in primary care and the community are likely to be inexpensive compared with usual care. Given the commonly accepted thresholds, they appear to be cost-effective on the whole, although there is notable variation between studies. PMID:26438429
Predictors of early discontinuation of basal insulin therapy in type 2 diabetes in primary care.

PubMed

Kostev, K; Dippel, F W; Rathmann, W

2016-04-01

To identify patient-related characteristics and other impact factors predicting early discontinuation of basal insulin therapy in type 2 diabetes in primary care. A total of 4837 patients who started basal insulin therapy (glargine: n=3175; NPH: n=1662) in 1072 general and internal medicine practices throughout Germany were retrospectively analyzed (Disease Analyser Database: 01/2008-03/2014). Early discontinuation was defined as switching back to oral antidiabetic drugs (OAD) therapy within 90 days after first basal insulin prescription (index date, ID). Patient records were assessed 365 days prior and post ID. Logistic regression models were used to adjust for age, sex, diabetes duration, diabetologist care, disease management program participation, HbA1c, and comorbidity. Within 3 months after ID, 202 (6.8%) of glargine patients switched back to OAD (NPH: 130 (8.5%); p<0.05). In multivariable logistic regression, predictors of early basal insulin discontinuation were ≥1 documented hypoglycemia before ID (adjusted Odds ratio; 95% CI: 2.20; 1.27-3.82), diagnosed depression (1.31; 1.01-1.70) and referrals to specialists within 90 days after ID (2.06; 1.61-2.63). Diabetologist care (0.57; 0.36-0.89) and glargine treatment (vs. NPH: 0.78; 0.61-0.98) were related to a lower odds of having early insulin discontinuation. Less than 10% of type 2 diabetes patients switched back to oral antidiabetic drugs within 90 days after start of basal insulin therapy. In particular, patients with baseline depression and frequent or severe hypoglycemia have a higher likelihood for early discontinuation of basal insulin, whereas use of insulin glargine and diabetologist care are related to an increased chance of continuous insulin treatment. Copyright © 2015 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Primary care physicians’ perspectives on facilitating older patients’ access to community support services

PubMed Central

Ploeg, Jenny; Denton, Margaret; Hutchison, Brian; McAiney, Carrie; Moore, Ainsley; Brazil, Kevin; Tindale, Joseph; Lam, Annie

2017-01-01

Abstract Objective To understand how family physicians facilitate older patients’ access to community support services (CSSs) and to identify similarities and differences across primary health care (PHC) models. Design Qualitative, multiple-case study design using semistructured interviews. Setting Four models of PHC delivery, specifically 2 family health teams (FHTs), 4 non-FHTs family health organizations, 4 fee-for-service practices, and 2 community health centres in urban Ontario. Participants Purposeful sampling of 23 family physicians in solo and small and large group practices within the 4 models of PHC. Methods A multiple-case study approach was used. Semistructured interviews were conducted and data were analyzed using within- and cross-case analysis. Case study tactics to ensure study rigour included memos and an audit trail, investigator triangulation, and the use of multiple, rather than single, case studies. Main findings Three main themes were identified: consulting and communicating with the health care team to create linkages; linking patients and families to CSSs; and relying on out-of-date resources and ineffective search strategies for information on CSSs. All participants worked with their team members; however, those in FHTs and community health centres generally had a broader range of health care providers available to assist them. Physicians relied on home-care case managers to help make linkages to CSSs. Physicians recommended the development of an easily searchable, online database containing available CSSs. Conclusion This study shows the importance of interprofessional teamwork in primary care settings to facilitate linkages of older patients to CSSs. The study also provides insight into the strategies physicians use to link older persons to CSSs and their recommendations for change. This understanding can be used to develop resources and approaches to better support physicians in making appropriate linkages to CSSs. PMID:28115458
Palliative management of pressure ulcers and malignant wounds in patients with advanced illness.

PubMed

McDonald, Amy; Lesage, Pauline

2006-04-01

Pressure ulcers and malignant wounds are prevalent in populations with advanced illness. In these populations, the goals of care may shift from a primary focus on healing to a focus on wound management, palliation and comfort. Many complications associated with these wounds must be palliated. This review explores the palliative approach to managing pressure ulcers and malignant wounds in patients with advanced illness. A comprehensive search of MEDLINE, CINAHL, and Cochrane Databases for articles addressing wound management and palliation was performed. We also reviewed online wound care resources and textbooks related to the field. The key to good wound care is prevention if possible, ongoing wound assessment, correct choice of dressing and use of available adjuvant therapies. The ultimate goals of palliative wound care are to control pain, to manage infection, odor, bleeding, and exudate, and to maintain a good quality of life for the patient and caregiver.
Various contract settings and their impact on the cost of medical services.

PubMed

Magnezi, R; Dankner, R; Kedem, R; Reuveni, H

2007-03-01

This study analyzes the effect of outsourcing healthcare on career soldiers in the Israel Defense Forces (IDF) in different settings, so as to develop a model for predicting per capita medical costs Demographic information and data on healthcare utilization and costs were gathered from three computerized billing database systems: The IDF Medical Corps; a civilian hospital; and a healthcare fund, providing services to 3,746; 3,971; and 6,400 career soldiers, respectively. Visits to primary care physicians and specialists, laboratory and imaging exams, number of sick-leave days, and hospitalization days, were totaled for men and women separately for each type of clinic. A uniform cost was assigned to each type of treatment to create an average annual per capita cost for medical services of career soldiers. Significantly more visits were recorded to primary care physician and to specialists, as well as imaging examinations by Leumit Healthcare Services (LHS), than visits and tests in hospitals or in military clinics (p < 0.001). The number of referrals to emergency rooms and sick-leave days were lowest in the LHS as compared to the hospital and military clinics (p < 0.001). The medical cost per capita/year was lowest in LHS as well. Outsourcing primary care for career soldiers to a civilian healthcare fund represents a major cost effective change, lowest consumption and lower cost of medical care. Co-payment should be integrated into every agreement with the medical corps.
Adherence to diagnostic guidelines and quality indicators in asthma and COPD in Swedish primary care.

PubMed

Weidinger, Paolina; Nilsson, J Lars G; Lindblad, Ulf

2009-05-01

To study the clinical evaluation and treatment of patients with asthma and COPD in primary care in Sweden, with a focus on adherence to recommended guidelines and quality indicators. All visits at health care centres in Skaraborg, Sweden, are documented in computerized medical records constituting the Skaraborg Primary Care Database (SPCD). In a register-based retrospective observational study, all patients diagnosed with asthma or COPD during 2000-2005 (n = 12,328) were identified. In a 5% random sample (n = 623), information on performed investigations at initial visits and at follow-up during 2004-2005 was collected. Compliance with procedures as recommended by national guidelines was used for quality assessment. Among 499 patients with asthma, 167 (33%) were investigated with spirometry or Peak Expiratory Flow (PEF) during initial visits in agreement with guidelines. Correspondingly, 40 out of 124 patients with COPD (32%) were investigated with spirometry. During follow-up, evaluation in agreement with guidelines was performed in 130 (60%) of patients with asthma and in 35 patients out of 77 (45%) with COPD. Prescribing of ICS reached quality target, still every second patient made an acute visit during follow-up. Adherence to recommended guidelines in asthma/COPD was low. Acute visits were common and despite the prescribing of ICS according to recommendations, patients still seem uncontrolled in their disease. There is a need for quality improvement in the clinical evaluation and treatment of patients with asthma and COPD.
Converting systematic reviews to Cochrane format: a cross-sectional survey of Australian authors of systematic reviews

PubMed Central

Piehl, Janet H; Green, Sally; McDonald, Steve

2003-01-01

Background Despite the growing reputation and subject coverage of the Cochrane Database of Systematic Reviews, many systematic reviews continue to be published solely in paper-based health care journals. This study was designed to determine why authors choose to publish their systematic reviews outside of the Cochrane Collaboration and if they might be interested in converting their reviews to Cochrane format for publication in the Cochrane Database of Systematic Reviews. Methods Cross-sectional survey of Australian primary authors of systematic reviews not published on the Cochrane Database of Systematic Reviews identified from the Database of Abstracts of Reviews of Effectiveness. Results We identified 88 systematic reviews from the Database of Abstracts of Reviews of Effectiveness with an Australian as the primary author. We surveyed 52 authors for whom valid contact information was available. The response rate was 88 per cent (46/52). Ten authors replied without completing the survey, leaving 36 valid surveys for analysis. The most frequently cited reasons for not undertaking a Cochrane review were: lack of time (78%), the need to undergo specific Cochrane training (46%), unwillingness to update reviews (36%), difficulties with the Cochrane process (26%) and the review topic already registered with the Cochrane Collaboration (21%). (Percentages based on completed responses to individual questions.) Nearly half the respondents would consider converting their review to Cochrane format. Dedicated time emerged as the most important factor in facilitating the potential conversion process. Other factors included navigating the Cochrane system, assistance with updating and financial support. Eighty-six per cent were willing to have their review converted to Cochrane format by another author. Conclusion Time required to complete a Cochrane review and the need for specific training are the primary reasons why some authors publish systematic reviews outside of the Cochrane Collaboration. Encouragingly, almost half of the authors would consider converting their review to Cochrane format. Based on the current number of reviews in the Database of Abstracts of Reviews of Effectiveness, this could result in more than 700 additional Cochrane reviews. Ways of supporting these authors and how to provide dedicated time to convert systematic reviews needs further consideration. PMID:12533194
The utility of liver function tests for mortality prediction within one year in primary care using the algorithm for liver function investigations (ALFI).

PubMed

McLernon, David J; Dillon, John F; Sullivan, Frank M; Roderick, Paul; Rosenberg, William M; Ryder, Stephen D; Donnan, Peter T

2012-01-01

Although liver function tests (LFTs) are routinely measured in primary care, raised levels in patients with no obvious liver disease may trigger a range of subsequent expensive and unnecessary management plans. The aim of this study was to develop and validate a prediction model to guide decision-making by general practitioners, which estimates risk of one year all-cause mortality in patients with no obvious liver disease. In this population-based historical cohort study, biochemistry data from patients in Tayside, Scotland, with LFTs performed in primary care were record-linked to secondary care and prescription databases to ascertain baseline characteristics, and to mortality data. Using this derivation cohort a survival model was developed to predict mortality. The model was assessed for calibration, discrimination (using the C-statistic) and performance, and validated using a separate cohort of Scottish primary care practices. From the derivation cohort (n = 95 977), 2.7% died within one year. Predictors of mortality included: age; male gender; social deprivation; history of cancer, renal disease, stroke, ischaemic heart disease or respiratory disease; statin use; and LFTs (albumin, transaminase, alkaline phosphatase, bilirubin, and gamma-glutamyltransferase). The C-statistic for the final model was 0.82 (95% CI 0.80-0.84), and was similar in the validation cohort (n = 11 653) 0.86 (0.79-0.90). As an example of performance, for a 10% predicted probability cut-off, sensitivity = 52.8%, specificity = 94.0%, PPV = 21.0%, NPV = 98.5%. For the model without LFTs the respective values were 43.8%, 92.8%, 15.6%, 98.1%. The Algorithm for Liver Function Investigations (ALFI) is the first model to successfully estimate the probability of all-cause mortality in patients with no apparent liver disease having LFTs in primary care. While LFTs added to the model's discrimination and sensitivity, the clinical utility of ALFI remains to be established since LFTs did not improve an already high NPV for short term mortality and only modestly improved a very low PPV.
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

Variability in the performance of preventive services and in the degree of control of identified health problems: A primary care study protocol

PubMed Central

Bolíbar, Bonaventura; Pareja, Clara; Astier-Peña, M Pilar; Morán, Julio; Rodríguez-Blanco, Teresa; Rosell-Murphy, Magdalena; Iglesias, Manuel; Juncosa, Sebastián; Mascort, Juanjo; Violan, Concepció; Magallón, Rosa; Apezteguia, Javier

2008-01-01

Background Preventive activities carried out in primary care have important variability that makes necessary to know which factors have an impact in order to establish future strategies for improvement. The present study has three objectives: 1) To describe the variability in the implementation of 7 preventive services (screening for smoking status, alcohol abuse, hypertension, hypercholesterolemia, obesity, influenza and tetanus immunization) and to determine their related factors; 2) To describe the degree of control of 5 identified health problems (smoking, alcohol abuse, hypertension, hypercholesterolemia and obesity); 3) To calculate intraclass correlation coefficients. Design Multi-centered cross-sectional study of a randomised sample of primary health care teams from 3 regions of Spain designed to analyse variability and related factors of 7 selected preventive services in years 2006 and 2007. At the end of 2008, we will perform a cross-sectional study of a cohort of patients attended in 2006 or 2007 to asses the degree of control of 5 identified health problems. All subjects older than16 years assigned to a randomised sample of 22 computerized primary health care teams and attended during the study period are included in each region providing a sample with more than 850.000 subjects. The main outcome measures will be implementation of 7 preventive services and control of 5 identified health problems. Furthermore, there will be 3 levels of data collection: 1) Patient level (age, gender, morbidity, preventive services, attendance); 2) Health-care professional level (professional characteristics, years working at the team, workload); 3) Team level (characteristics, electronic clinical record system). Data will be transferred from electronic clinical records to a central database with prior encryption and dissociation of subject, professional and team identity. Global and regional analysis will be performed including standard analysis for primary health care teams and health-care professional level. Linear and logistic regression multilevel analysis adjusted for individual and cluster variables will also be performed. Variability in the number of preventive services implemented will be calculated with Poisson multilevel models. Team and health-care professional will be considered random effects. Intraclass correlation coefficients, standard error and variance components for the different outcome measures will be calculated. PMID:18691407
How do nurse practitioners work in primary health care settings? A scoping review.

PubMed

Grant, Julian; Lines, Lauren; Darbyshire, Philip; Parry, Yvonne

2017-10-01

This scoping review explores the work of nurse practitioners in primary health care settings in developed countries and critiques their contribution to improved health outcomes. A scoping review design was employed and included development of a research question, identification of potentially relevant studies, selection of relevant studies, charting data, collating, summarising and reporting findings. An additional step was added to evaluate the methodological rigor of each study. Data sources included literature identified by a search of electronic databases conducted in September 2015 (CINAHL, Informit, Web of Science, Scopus and Medline) and repeated in July 2016. Additional studies were located through hand searching and authors' knowledge of other relevant studies. 74 articles from eight countries were identified, with the majority emanating from the United States of America. Nurse practitioners working in communities provided care mostly in primary care centres (n=42), but also in community centres (n=6), outpatient departments (n=6), homes (n=5), schools (n=3), child abuse clinics (n=1), via communication technologies (n=6), and through combined face-to-face and communication technologies (n=5). The scope of nurse practitioner work varied on a continuum from being targeted towards a specific disease process or managing individual health and wellbeing needs in a holistic manner. Enhanced skills included co-ordination, collaboration, education, counselling, connecting clients with services and advocacy. Measures used to evaluate outcomes varied widely from physiological data (n=25), hospital admissions (n=10), use of health services (n=15), self-reported health (n=13), behavioural change (n=14), patient satisfaction (n=17), cost savings (n=3) and mortality/morbidity (n=5). The majority of nurse practitioners working in community settings did so within a selective model of primary health care with some examples of nurse practitioners contributing to comprehensive models of primary health care. Nurse practitioners predominantly worked with populations defined by an illness with structured protocols for curative and rehabilitative care. Nurse practitioner work that also incorporated promotive activities targeted improving social determinants of health for people rendered vulnerable due to ethnicity, Aboriginal identity, socioeconomic disadvantage, remote location, gender and aging. Interventions were at individual and community levels with outcomes including increased access to care, cost savings and salutogenic characteristics of empowerment for social change. Copyright © 2017 Elsevier Ltd. All rights reserved.
Integrated care in rural health: Seeking sustainability.

PubMed

Peterson, Mary; Turgesen, Jeri; Fisk, Laura; McCarthy, Seamus

2017-06-01

The increased awareness of the financial impact associated with social determinants of health coincides with expectations of the Affordable Care Act (HR 3590) to improve care while reducing costs. The integration of behavioral health providers (BHPs) into primary care has demonstrated improved clinical outcomes. This study was designed with 2 aims, including the evaluation of the financial viability of an integrated care model in a rural setting and the demonstration of incorporating practice-based research into clinical work. A rural health plan caring for 22,000 members funded a pilot project placing BHPs in 3 clinics to provide integrated care. Patient utilization of medical services for 6 months following BHP services was compared with baseline utilization. The BHPs treated 256 unique patients, with a total of 459 consultations. The percentage of patients receiving BHP services varied between clinics (Clinic A = 1.4%, Clinic B = 2.7%, and Clinic C = 3.9%). A between-clinic analysis showed differences in medical claims data between baseline and post-BH services. The overall effect sizes for reduced medical utilization for patients at clinics B and C were very large, Hedge's g = -2.31 and -4.79, respectively. Utilization of 4 of the services (emergency, lab, outpatient, and primary care) showed the large reductions in their costs. In contrast, the data for Clinic A showed no change. Patients receiving behavioral health services within the integrated care model may decrease utilization of medical services following treatment, resulting in cost offset. Potential reasons for variability between clinics are discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
A third of patients treated at a tertiary-level surgical service could be treated at a secondary-level facility.

PubMed

Van Straten, S; Stannard, C; Bulabula, J; Boodhia, K; Paul, K; Leong, J; Klipin, M J

2017-08-25

South Africa (SA) has an overburdened public healthcare system. Some patients admitted to Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), SA, may not require tertiary care, but the numbers and details are uncertain. Clinical research in SA is limited by scarce skills and limited access to data. To determine the proportion of and length of stay for secondary-, tertiary- and quaternary-level patients discharged from the Department of Surgery at CMJAH over 1 year. This is a retrospective analysis of electronic discharge (ED) summaries from the Department of Surgery at CMJAH between 1 April 2015 and 1 April 2016. An SQL query of the database generated a .csv file of all discharges with the following fields: database reference number, length of stay and level of care. The details of each record were verified by MBBCh V students, using a defined level-ofcare template and the full discharge summary. The data were reviewed by a senior clinician. There were 3 007 discharge summaries - 97 were not classifiable, two were test records and one was a duplicate. These 100 records were excluded. There were no primary-level records. Secondary-level patients represented 29% (854) of those discharged and 19% of total bed days. Tertiary- and quaternary-level patients together represented 71% of the total and 81% of bed days. The average length of stay was 4.31 days for secondary, 6.98 days for tertiary and 9.77 days for quaternary level-of-care allocation. Almost one-third (29%) of patients discharged from CMJAH's Department of Surgery were deemed suitable for secondarylevel care. These patients had a shorter length of stay and comprised 19% of total bed days. Students and electronic databases represent an important research resource.
Association of Palliative Care Consultation With Reducing Inpatient Chemotherapy Use in Elderly Patients With Cancer in Japan: Analysis Using a Nationwide Administrative Database.

PubMed

Sano, Motoko; Fushimi, Kiyohide

2017-08-01

The administration of chemotherapy at the end of life is considered an aggressive life-prolonging treatment. The use of unnecessarily aggressive therapy in elderly patients at the end of life is an important health-care concern. To explore the impact of palliative care consultation (PCC) on chemotherapy use in geriatric oncology inpatients in Japan by analyzing data from a national database. We conducted a multicenter cohort study of patients aged ≥65 years, registered in the Japan National Administrative Healthcare Database, who died with advanced (stage ≥3) lung, stomach, colorectal, liver, or breast cancer while hospitalized between April 2010 and March 2013. The relationship between PCC and chemotherapy use in the last 2 weeks of life was analyzed using χ 2 and logistic regression analyses. We included 26 012 patients in this analysis. The mean age was 75.74 ± 6.40 years, 68.1% were men, 81.8% had recurrent cancer, 29.5% had lung cancer, and 29.5% had stomach cancer. Of these, 3134 (12%) received PCC. Among individuals who received PCC, chemotherapy was administered to 46 patients (1.5%) and was not administered to 3088 patients (98.5%). Among those not receiving PCC, chemotherapy was administered to 909 patients (4%) and was not administered to the remaining 21 978 patients (96%; odds ratio [OR], 0.35; 95% confidence interval, 0.26-0.48). The OR of chemotherapy use was higher in men, young-old, and patients with primary cancer. Palliative care consultation was associated with less chemotherapy use in elderly Japanese patients with cancer who died in the hospital setting.
Medical professional liability claims for Mohs micrographic surgery from 1989 to 2011.

PubMed

D'Souza, Logan S; Jalian, H Ray; Jalian, Chris; Alam, Murad; Eisen, Daniel B; Avram, Mathew M; Ibrahimi, Omar A

2015-05-01

Few studies specifically address lawsuits involving Mohs surgery. To better characterize the types of medical professional liability claims involving Mohs surgery. Retrospective legal document review of an online national database. Any legal proceeding involving the search words Mohs and cancer was included. Number of medical professional liability claims involving Mohs surgery for factors including year of litigation, location, physician specialty, injury sustained, cause of legal action, and verdict. Forty-two cases were identified, which occurred from 1989 to 2011. Of the cases identified, 26 involved non-Mohs surgeons as the primary defendant, mostly due to a delay of or failure in diagnosis (n = 16), cosmetic outcome issues (n = 8), lack of informed consent (n = 7), and a delay of or failure in referral to a Mohs surgeon (n = 6). Common causes for litigation against Mohs surgeons as the primary defendant (n = 16) were lack of proper informed consent (n = 5) and cosmetic outcome issues (n = 4). Only 1 case against a Mohs surgeon was judged for the plaintiff. The most common lawsuits pertaining to Mohs surgery list non-Mohs surgeons as the primary defendants. Closer coordination between non-Mohs surgeons and Mohs surgeons may help minimize risk to both parties and lead to better patient care. Small sample size is the primary limitation, in part owing to exclusion of out-of-court settlements from the database.
Improving outpatient primary medication adherence with physician guided, automated dispensing

PubMed Central

Moroshek, Jacob G

2017-01-01

Background Physician dispensing, different from pharmacist dispensing, is a way for practitioners to supply their patients with medications, at the point of care. The InstyMeds dispenser and logistics system can automate much of the dispensing, insurance adjudication, inventory management, and regulatory reporting that is required of physician dispensing. Objective To understand the percentage of patients that exhibit primary adherence to medication in the outpatient setting when choosing InstyMeds. Method The InstyMeds dispensing database was de-identified and analyzed for primary adherence. This is the ratio of patients who dispensed their medication to those who received an eligible prescription. Results The average InstyMeds emergency department installation has a primary adherence rate of 91.7%. The maximum rate for an installed device was 98.5%. Conclusion Although national rates of primary adherence have been found to be in the range of 70%, automated physician dispensing vastly improves the rate of adherence. Improved adherence should lead to better patient outcomes, fewer return visits, and lower healthcare costs. PMID:28115860
Risk of hypoglycaemia in type 2 diabetes patients under different insulin regimens: a primary care database analysis.

PubMed

Kostev, Karel; Dippel, Franz W; Rathmann, Wolfgang

2015-01-01

To compare rates and predictors of documented hypoglycaemia in type 2 diabetes patients treated with either basal insulin supported oral therapy (BOT), conventional therapy (CT) or supplementary insulin therapy (SIT) in primary care. Data from 10,842 anonymous patients (mean age ± SD: 54 ± 8 yrs) on BOT, 2,407 subjects (56 ± 7 yrs) on CT, and 7,480 patients (52 ± 10 yrs) using SIT from 1,198 primary care practices were retrospectively analyzed (Disease Analyzer, Germany: 01/2005-07/2013). Stepwise logistic regression (≥1 documented hypoglycaemia: ICD code) was used to evaluate risk factors of hypoglycemia. The unadjusted rates (95% CI) per 100 patient-years of documented hypoglycaemia were 1.01 (0.80-1.20) (BOT), 1.68 (1.10-2.30) (CT), and 1.61 (1.30-1.90) (SIT), respectively. The odds of having ≥1 hypoglycemia was increased for CT (OR; 95% CI: 1.71; 1.13-2.58) and SIT (1.55; 1.15-2.08) (reference: BOT). Previous hypoglycemia (OR: 11.24; 6.71-18.85), duration of insulin treatment (days) (1.06; 1.05-1.07), history of transient ischemic attack (TIA)/stroke (1.91; 1.04-3.50), and former salicylate prescriptions (1.44; 1.06-1.98) also showed an increased odds of having hypoglycemia. Higher age was associated with a slightly lower odds ratio (per year: 0.98; 0.97-0.99). Insulin naïve type 2 diabetes patients in primary care, initiated with CT and SIT have an increased risk of hypoglycaemia compared to BOT, which is in line with previous randomized controlled trials. As hypoglycaemic events are associated with an increased mortality risk, this real-world finding is of clinical relevance.
Ventricular fibrillation in acute myocardial infarction in Spanish patients: Results of the ARIAM database.

PubMed

Ruiz-Bailén, Manuel; Aguayo de Hoyos, Eduardo; Ruiz-Navarro, Silvia; Issa-Khozouz, Ziad; Reina-Toral, Antonio; Díaz-Castellanos, Miguel Angel; Rodríguez-García, Juan-José; Torres-Ruiz, Juan Miguel; Cárdenas-Cruz, Antonio; Camacho-Víctor, Angel

2003-08-01

The aim of this study has been to investigate the factors predisposing to primary or secondary ventricular fibrillation (VF) and the prognosis in Spanish patients with acute myocardial infarction (AMI) during their admission to the intensive care unit or the coronary care unit. A retrospective, observational study. The intensive care units and coronary care units of 119 Spanish hospitals. A retrospective cohort study including all the AMI patients listed in the ARIAM registry (Analysis of Delay in Acute Myocardial Infarction), a Spanish multicenter study. The study period was January 1995 to January 2001. Factors associated with the onset of VF were studied by univariate analysis. Multivariate analysis was used to evaluate the independent factors for the onset of VF and for mortality. A total of 17,761 patients with AMI were included in the study; 964 (5.4%) developed VF (primary in 735 patients, secondary in 229). In multivariate analysis, the variables that continued to show an association with the development of VF were the Killip and Kimball class, peak creatine kinase, APACHE II score, age, and time from the onset of symptoms to the initiation of thrombolysis. The mortality in the patients with any VF was 31.8% (27.8% in patients with primary VF and 49.1% in patients with secondary VF). The development of VF is an independent predictive factor for mortality in patients with AMI, with a crude odds ratio of 5.12 (95% confidence interval, 4.41-5.95) and an adjusted odds ratio of 2.73 (95% confidence interval, 2.12-3.51). Despite the considerable improvement in the treatment of AMI in recent years, the onset of either primary or secondary VF is associated with a poor prognosis. It is usually accompanied by extensive necrosis.
Predictors of human immunodeficiency virus (HIV) infection in primary care: a systematic review protocol.

PubMed

Rumbwere Dube, Benhildah N; Marshall, Tom P; Ryan, Ronan P

2016-09-20

Antiretroviral therapies for human immunodeficiency virus are more effective if infected individuals are diagnosed early, before they have irreversible immunologic damage. A large proportion of patients that are diagnosed with HIV, in United Kingdom, would have seen a general practitioner (GP) within the previous year. Determining the demographic and clinical characteristics of HIV-infected patients prior to diagnosis of HIV may be useful in identifying patients likely to be HIV positive in primary care. This could help inform a strategy of early HIV testing in primary care. This systematic review aims to identify characteristics of HIV-infected adults prior to diagnosis that could be used in a prediction model for early detection of HIV in primary care. The systematic review will search for literature, mainly observational (cohort and case-control) studies, with human participants aged 18 years and over. The exposures are demographic, socio-economic or clinical risk factors or characteristics associated with HIV infection. The comparison group will be patients with no risk factors or no comparison group. The outcome is laboratory-confirmed HIV/AIDS infection. Evidence will be identified from electronic searches of online databases of EMBASE, MEDLINE, The Cochrane Library and grey literature search engines of Open Grey, Web of Science Conference Proceedings Citation Index and examination of reference lists from selected studies (reference searching). Two reviewers will be involved in quality assessment and data extraction of the review. A data extraction form will be developed to collate data from selected studies. A checklist for quality assessment will be adapted from the Scottish Intercollegiate Guidelines Network (SIGN). This systematic review will identify and consolidate existing scientific evidence on characteristics of HIV infected individuals that could be used to inform decision-making in prognostic model development. PROSPERO CRD42016042427.
Adult obesity prevalence in primary care users: An exploration using Canadian Primary Care Sentinel Surveillance Network (CPCSSN) data.

PubMed

Rigobon, Alanna V; Birtwhistle, Richard; Khan, Shahriar; Barber, David; Biro, Suzanne; Morkem, Rachael; Janssen, Ian; Williamson, Tyler

2015-04-30

This research examines the feasibility of using electronic medical records within the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) for obesity surveillance in Canada by assessing obesity trends over time and comparing BMI distribution estimates from CPCSSN to those obtained from nationally representative surveys. Data from 2003-2012 on patients 18 years and older (n = 216,075) were extracted from the CPCSSN database. Patient information included demographics (age and sex) and anthropometric measures (height, weight, body mass index (BMI), waist circumference, and waist-to-hip ratio). Standard descriptive statistics were used to characterize the sample, including, as appropriate, means, proportions and medians. The BMI distribution of the CPCSSN population was compared to estimates from the Canadian Community Health Survey (CCHS) and the Canadian Health Measures Survey (CHMS) for the years: 2004, 2007-2009 and 2009-2011. The estimated prevalence of obesity increased from 17.9% in 2003 to 30.8% in 2012. Obesity class I, II and III prevalence estimates from CPCSSN in 2009-2011 (18.0%, 95% CI: 17.8-18; 7.4%, 95% CI: 7.3-7.6; 4.2%, 95% CI: 4.1-4.3 respectively) were greater than those from the most recent (2009- 2011) cycle of the CHMS (16.2%, 95% CI: 14-18.7; 6.3%, 95% CI: 4.6-8.5; 3.7%, 95% CI: 2.8-4.8 respectively), however these differences were not statistically significant. The data from CPCSSN present a unique opportunity for longitudinal obesity surveillance among primary care users in Canada, and offer prevalence estimates similar to those obtained from nationally representative survey data.
A systematic review and evidence synthesis of qualitative studies to identify primary care clinicians' barriers and enablers to the management of osteoarthritis.

PubMed

Egerton, T; Diamond, L E; Buchbinder, R; Bennell, K L; Slade, S C

2017-05-01

Primary care management of osteoarthritis (OA) is variable and often inconsistent with clinical practice guidelines (CPGs). This study aimed to identify and synthesize available qualitative evidence on primary care clinicians' views on providing recommended management of OA. Eligibility criteria included full reports published in peer-reviewed journals, with data collected directly from primary care clinicians using qualitative methods for collection and analysis. Five electronic databases (MEDLINE, Cochrane Central Register, EMBASE, CINAHL and PsychInfo) were searched to August 2016. Two independent reviewers identified eligible reports, conducted critical appraisal (based on Critical Appraisal Skills Programme (CASP) criteria), and extracted data. Three reviewers independently, then collaboratively, synthesized and interpreted data through an inductive and iterative process to derive new themes. The Confidence in Evidence from Reviews of Qualitative research (CERQual) approach was used to determine a confidence profile for each finding. Eight studies involving approximately 83 general practitioners (GPs), 24 practice nurses, 12 pharmacists and 10 physical therapists, from Australia, France, United Kingdom, Germany and Mexico were included. Four barriers were identified as themes 1) OA is not that serious, 2) Clinicians are, or perceive they are, under-prepared, 3) Personal beliefs at odds with providing recommended practice, and 4) Dissonant patient expectations. No themes were enablers. Confidence ratings were moderate or low. Synthesising available data revealed barriers that collectively point towards a need to address clinician knowledge gaps, and enhance clinician communication and behaviour change skills to facilitate patient adherence, enable effective conversations and manage dissonant patient expectations. PROSPERO (http://www.crd.york.ac.uk/PROSPERO) [4/11/2015, CRD42015027543]. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.
The diagnostic test accuracy of rectal examination for prostate cancer diagnosis in symptomatic patients: a systematic review.

PubMed

Jones, Daniel; Friend, Charlotte; Dreher, Andreas; Allgar, Victoria; Macleod, Una

2018-06-02

Prostate cancer is the most common cancer in men in the UK. NICE guidelines on recognition and referral of suspected cancer, recommend performing digital rectal examination (DRE) on patients with urinary symptoms and urgently referring if the prostate feels malignant. However, this is based on the results of one case control study, so it is not known if DRE performed in primary care is an accurate method of detecting prostate cancer. The aim of this review is to ascertain the sensitivity, specificity, positive and negative predictive value of DRE for the detection of prostate cancer in symptomatic patients in primary care. CENTRAL, MEDLINE, EMBASE and CINAHL databases were searched in august 2015 for studies in which a DRE was performed in primary care on symptomatic patients and compared against a reference diagnostic procedure. Four studies were included with a total of 3225 patients. The sensitivity and specificity for DRE as a predictor of prostate cancer in symptomatic patients was 28.6 and 90.7%, respectively. The positive and negative predictive values were 42.3 and 84.2%, respectively. This review found that DRE performed in general practice is accurate, and supports the UK NICE guidelines that patients with a malignant prostate on examination are referred urgently for suspected prostate cancer. Abnormal DRE carried a 42.3% chance of malignancy, above the 3% risk threshold which NICE guidance suggests warrants an urgent referral. However this review questions the benefit of performing a DRE in primary care in the first instance, suggesting that a patient's risk of prostate cancer based on symptoms alone would warrant urgent referral even if the DRE feels normal.
Physician gender and patient-centered communication: a critical review of empirical research.

PubMed

Roter, Debra L; Hall, Judith A

2004-01-01

Physician gender has stimulated a good deal of interest as a possible source of variation in the interpersonal aspects of medical practice, with speculation that female physicians are more patient-centered in their communication with patients. Our objective is to synthesize the results of two meta-analytic reviews the effects of physician gender on communication in medical visits within a communication framework that reflects patient-centeredness and the functions of the medical visit. We performed online database searches of English-language abstracts for the years 1967 to 2001 (MEDLINE, AIDSLINE, PsycINFO, and BIOETHICS), and a hand search was conducted of reprint files and the reference sections of review articles and other publications. Studies using a communication data source such as audiotape, videotape, or direct observation were identified through bibliographic and computerized searches. Medical visits with female physicians were, on average, two minutes (10%) longer than those of male physicians. During this time, female physicians engaged in significantly more communication that can be considered patient-centered. They engaged in more active partnership behaviors, positive talk, psychosocial counseling, psychosocial question asking, and emotionally focused talk. Moreover, the patients of female physicians spoke more overall, disclosed more biomedical and psychosocial information, and made more positive statements to their physicians than did the patients of male physicians. Obstetrics and gynecology may present a pattern different from that of primary care: Male physicians demonstrated higher levels of emotionally focused talk than their female colleagues. Female primary care physicians and their patients engaged in more communication that can be considered patient-centered and had longer visits than did their male colleagues. Limited studies exist outside of primary care, and gender-related practice patterns might differ in some subspecialties from those evident in primary care.
The National Data Bank for Rheumatic Diseases (NDB).

PubMed

Michaud, Kaleb

2016-01-01

The National Data Bank for Rheumatic Diseases (NDB) is a longitudinal observational patient-driven database, founded as a non-profit research organization in 1998 by Dr. Frederick Wolfe. Patients are sent a primary questionnaire twice a year. More than 50,000 patients with more than 100 various rheumatic diseases under the care of more than 1,500 rheumatologists have completed at least one 6-month questionnaire. Many important publications concerning rheumatoid arthritis, osteoarthritis, systemic lupus erythematosus, fibromyalgia, and pharmaco-epidemiology have resulted from NDB research.
Impact of office systems and improvement strategies on costs of care for adults with diabetes.

PubMed

Gilmer, Todd P; O'Connor, Patrick J; Rush, William A; Crain, A Lauren; Whitebird, Robin R; Hanson, Anne M; Solberg, Leif I

2006-06-01

To assess the impact of organizational features and improvement strategies of primary care clinics on health care costs of adults with diabetes. This study included a prospective cohort study of 1,628 adults with diabetes in a large, health care organization receiving care in 84 clinics within 18 medical groups. Data from surveys of patients, clinic medical directors and managers, and medical record reviews were merged with 3 years of medical claims. Costs were estimated using health plan data on resource use and common Medicare payment methodologies. Generalized linear regression models were used to analyze costs related to clinic characteristics, adjusting for individual patient comorbidity, demographic, and socioeconomic factors. Clinics with regular clinician meetings to discuss patient care problems and clinics that used diabetes registries to prioritize patients based on cardiovascular risk were associated with lower 3-year costs: -$3,962 (P = 0.002) and -$2,916 (P = 0.019), respectively. The use of databases to monitor lab results was associated with higher costs ($2,439, P = 0.038). Quality improvement strategies focused on resource use related to diabetes care (-$2,883, P = 0.017) or heart disease care (-$3,228, P = 0.014) were associated with lowered costs, whereas quality improvement strategies that emphasized pharmacy use for patients with heart disease ($3,059, P = 0.029) or depression ($2,962, P = 0.038) were associated with increased costs. Several organizational features of primary care offices were significant predictors of future health care costs for adults with diabetes. The mechanism by which such factors affect costs of care and the relationship of costs to clinical outcomes merits further evaluation.
Implementation of integrated care for diabetes mellitus type 2 by two Dutch care groups: a case study.

PubMed

Busetto, Loraine; Luijkx, Katrien; Huizing, Anna; Vrijhoef, Bert

2015-08-21

Even though previous research has demonstrated improved outcomes of integrated care initiatives, it is not clear why and when integrated care works. This study aims to contribute to filling this knowledge gap by examining the implementation of integrated care for type 2 diabetes by two Dutch care groups. An embedded single case study was conducted including 26 interviews with management staff, care purchasers and health professionals. The Context + Mechanism = Outcome Model was used to study the relationship between context factors, mechanisms and outcomes. Dutch integrated care involves care groups, bundled payments, patient involvement, health professional cooperation and task substitution, evidence-based care protocols and a shared clinical information system. Community involvement is not (yet) part of Dutch integrated care. Barriers to the implementation of integrated care included insufficient integration between the patient databases, decreased earnings for some health professionals, patients' insufficient medical and policy-making expertise, resistance by general practitioner assistants due to perceived competition, too much care provided by practice nurses instead of general practitioners and the funding system incentivising the provision of care exactly as described in the care protocols. Facilitators included performance monitoring via the care chain information system, increased earnings for some health professionals, increased focus on self-management, innovators in primary and secondary care, diabetes nurses acting as integrators and financial incentives for guideline adherence. Economic and political context and health IT-related barriers were discussed as the most problematic areas of integrated care implementation. The implementation of integrated care led to improved communication and cooperation but also to insufficient and unnecessary care provision and deteriorated preconditions for person-centred care. Dutch integrated diabetes care is still a work in progress, in the academic and the practice setting. This makes it difficult to establish whether overall quality of care has improved. Future efforts should focus on areas that this study found to be problematic or to not have received enough attention yet. Increased efforts are needed to improve the interoperability of the patient databases and to keep the negative consequences of the bundled payment system in check. Moreover, patient and community involvement should be incorporated.
Feasibility and impact of a computer-guided consultation on guideline-based management of COPD in general practice.

PubMed

Angus, Robert M; Thompson, Elizabeth B; Davies, Lisa; Trusdale, Ann; Hodgson, Chris; McKnight, Eddie; Davies, Andrew; Pearson, Mike G

2012-12-01

Applying guidelines is a universal challenge that is often not met. Intelligent software systems that facilitate real-time management during a clinical interaction may offer a solution. To determine if the use of a computer-guided consultation that facilitates the National Institute for Health and Clinical Excellence-based chronic obstructive pulmonary disease (COPD) guidance and prompts clinical decision-making is feasible in primary care and to assess its impact on diagnosis and management in reviews of COPD patients. Practice nurses, one-third of whom had no specific respiratory training, undertook a computer-guided review in the usual consulting room setting using a laptop computer with the screen visible to them and to the patient. A total of 293 patients (mean (SD) age 69.7 (10.1) years, 163 (55.6%) male) with a diagnosis of COPD were randomly selected from GP databases in 16 practices and assessed. Of 236 patients who had spirometry, 45 (19%) did not have airflow obstruction and the guided clinical history changed the primary diagnosis from COPD in a further 24 patients. In the 191 patients with confirmed COPD, the consultations prompted management changes including 169 recommendations for altered prescribing of inhalers (addition or discontinuation, inhaler dose or device). In addition, 47% of the 55 current smokers were referred for smoking cessation support, 12 (6%) for oxygen assessment, and 47 (24%) for pulmonary rehabilitation. Computer-guided consultations are practicable in general practice. Primary care COPD databases were confirmed to contain a significant proportion of incorrectly assigned patients. They resulted in interventions and the rationalisation of prescribing in line with recommendations. Only in 22 (12%) of those fully assessed was no management change suggested. The introduction of a computer-guided consultation offers the prospect of comprehensive guideline quality management.
The impact of primary care reform on health system performance in Canada: a systematic review.

PubMed

Carter, Renee; Riverin, Bruno; Levesque, Jean-Frédéric; Gariepy, Geneviève; Quesnel-Vallée, Amélie

2016-07-30

We aimed to synthesize the evidence of a causal effect and draw inferences about whether Canadian primary care reforms improved health system performance based on measures of health service utilization, processes of care, and physician productivity. We searched the Embase, PubMed and Web of Science databases for records from 2000 to September 2015. We based our risk of bias assessment on the Grading of Recommendations Assessment, Development and Evaluation guidelines. Full-text studies were synthesized and organized according to the three outcome categories: health service utilization, processes of care, and physician costs and productivity. We found moderate quality evidence that team-based models of care led to reductions in emergency department use, but the evidence was mixed for hospital admissions. We also found low quality evidence that team-based models, blended capitation models and pay-for-performance incentives led to small and sometimes non-significant improvements in processes of care. Studies examining new payment models on physician costs and productivity were of high methodological quality and provided a coherent body of evidence assessing enhanced fee-for-service and blended capitation payment models. A small number of studies suggested that team-based models contributed to reductions in emergency department use in Quebec and Alberta. Regarding processes of diabetes care, studies found higher rates of testing for blood glucose levels, retinopathy and cholesterol in Alberta's team-based primary care model and in practices eligible for pay-for-performance incentives in Ontario. However pay-for-performance in Ontario was found to have null to moderate effects on other prevention and screening activities. Although blended capitation payment in Ontario contributed to decreases in the number of services delivered and patients seen per day, the number of enrolled patients and number of days worked in a year was similar to that of enhanced fee-for-service practices.
A database of biological and geomorphological sea-level markers from the Last Glacial Maximum to present

PubMed Central

Hibbert, F.D.; Williams, F.H.; Fallon, S.J.; Rohling, E.J.

2018-01-01

The last deglacial was an interval of rapid climate and sea-level change, including the collapse of large continental ice sheets. This database collates carefully assessed sea-level data from peer-reviewed sources for the interval 0 to 25 thousand years ago (ka), from the Last Glacial Maximum to the present interglacial. In addition to facilitating site-specific reconstructions of past sea levels, the database provides a suite of data beyond the range of modern/instrumental variability that may help hone future sea-level projections. The database is global in scope, internally consistent, and contains U-series and radiocarbon dated indicators from both biological and geomorpohological archives. We focus on far-field data (i.e., away from the sites of the former continental ice sheets), but some key intermediate (i.e., from the Caribbean) data are also included. All primary fields (i.e., sample location, elevation, age and context) possess quantified uncertainties, which—in conjunction with available metadata—allows the reconstructed sea levels to be interpreted within both their uncertainties and geological context. PMID:29809175

Barriers to evidence-based medicine: a systematic review.

PubMed

Sadeghi-Bazargani, Homayoun; Tabrizi, Jafar Sadegh; Azami-Aghdash, Saber

2014-12-01

Evidence-based medicine (EBM) has emerged as an effective strategy to improve health care quality. The aim of this study was to systematically review and carry out an analysis on the barriers to EBM. Different database searching methods and also manual search were employed in this study using the search words ('evidence-based' or 'evidence-based medicine' or 'evidence-based practice' or 'evidence-based guidelines' or 'research utilization') and (barrier* or challenge or hinder) in the following databases: PubMed, Scopus, Web of Knowledge, Cochrane library, Pro Quest, Magiran, SID. Out of 2592 articles, 106 articles were finally identified for study. Research barriers, lack of resources, lack of time, inadequate skills, and inadequate access, lack of knowledge and financial barriers were found to be the most common barriers to EBM. Examples of these barriers were found in primary care, hospital/specialist care, rehabilitation care, medical education, management and decision making. The most common barriers to research utilization were research barriers, cooperation barriers and changing barriers. Lack of resources was the most common barrier to implementation of guidelines. The result of this study shows that there are many barriers to the implementation and use of EBM. Identifying barriers is just the first step to removing barriers to the use of EBM. Extra resources will be needed if these barriers are to be tackled. © 2014 John Wiley & Sons, Ltd.
A multicenter study of primary brain tumor incidence in Australia (2000–2008)

PubMed Central

Dobes, Martin; Shadbolt, Bruce; Khurana, Vini G.; Jain, Sanjiv; Smith, Sarah F.; Smee, Robert; Dexter, Mark; Cook, Raymond

2011-01-01

There are conflicting reports from Europe and North America regarding trends in the incidence of primary brain tumor, whereas the incidence of primary brain tumors in Australia is currently unknown. We aimed to determine the incidence in Australia with age-, sex-, and benign-versus-malignant histology-specific analyses. A multicenter study was performed in the state of New South Wales (NSW) and the Australian Capital Territory (ACT), which has a combined population of >7 million with >97% rate of population retention for medical care. We retrospectively mined pathology databases servicing neurosurgical centers in NSW and ACT for histologically confirmed primary brain tumors diagnosed from January 2000 through December 2008. Data were weighted for patient outflow and data completeness. Incidence rates were age standardized and trends analyzed using joinpoint analysis. A weighted total of 7651 primary brain tumors were analyzed. The overall US-standardized incidence of primary brain tumors was 11.3 cases 100 000 person-years (±0.13; 95% confidence interval, 9.8–12.3) during the study period with no significant linear increase. A significant increase in primary malignant brain tumors from 2000 to 2008 was observed; this appears to be largely due to an increase in malignant tumor incidence in the ≥65-year age group. This collection represents the most contemporary data on primary brain tumor incidence in Australia. Whether the observed increase in malignant primary brain tumors, particularly in persons aged ≥65 years, is due to improved detection, diagnosis, and care delivery or a true change in incidence remains undetermined. We recommend a direct, uniform, and centralized approach to monitoring primary brain tumor incidence that can be independent of multiple interstate cancer registries. PMID:21727214
An algorithm to identify rheumatoid arthritis in primary care: a Clinical Practice Research Datalink study

PubMed Central

Muller, Sara; Hider, Samantha L; Raza, Karim; Stack, Rebecca J; Hayward, Richard A; Mallen, Christian D

2015-01-01

Objective Rheumatoid arthritis (RA) is a multisystem, inflammatory disorder associated with increased levels of morbidity and mortality. While much research into the condition is conducted in the secondary care setting, routinely collected primary care databases provide an important source of research data. This study aimed to update an algorithm to define RA that was previously developed and validated in the General Practice Research Database (GPRD). Methods The original algorithm consisted of two criteria. Individuals meeting at least one were considered to have RA. Criterion 1: ≥1 RA Read code and a disease modifying antirheumatic drug (DMARD) without an alternative indication. Criterion 2: ≥2 RA Read codes, with at least one ‘strong’ code and no alternative diagnoses. Lists of codes for consultations and prescriptions were obtained from the authors of the original algorithm where these were available, or compiled based on the original description and clinical knowledge. 4161 people with a first Read code for RA between 1 January 2010 and 31 December 2012 were selected from the Clinical Practice Research Datalink (CPRD, successor to the GPRD), and the criteria applied. Results Code lists were updated for the introduction of new Read codes and biological DMARDs. 3577/4161 (86%) of people met the updated algorithm for RA, compared to 61% in the original development study. 62.8% of people fulfilled both Criterion 1 and Criterion 2. Conclusions Those wishing to define RA in the CPRD, should consider using this updated algorithm, rather than a single RA code, if they wish to identify only those who are most likely to have RA. PMID:26700281
The impact of transitional care programs on health services utilization in community-dwelling older adults: a systematic review.

PubMed

Weeks, Lori E; Macdonald, Marilyn; Martin-Misener, Ruth; Helwig, Melissa; Bishop, Andrea; Iduye, Damilola F; Moody, Elaine

2018-02-01

The objective was to identify and synthesize the best available evidence on the impact of transitional care programs on various forms of health services utilization in community-dwelling older adults. There is growing evidence that transitional care programs can help address important challenges facing health care systems and our increasing older adult population in many countries by reducing unnecessary health service utilization. There is a need for a systematic review of the research evaluating the impact of transitional care programs on hospital and other health service usage. The review included studies on community-dwelling adults age 60 and over with at least one medical diagnosis, and which evaluated the outcomes of transitional care programs on health system utilization of older adults. The outcomes for this review were hospital usage including admissions and readmissions, emergency department usage, primary care/physician usage, nursing home usage, and home health care usage. The review considered experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies, and case-control studies. A three-step search was utilized to find published and unpublished studies conducted in any country but reported in English. Six electronic databases were searched from inception of the database to May, 2016. A search for unpublished studies was also conducted. Methodological quality was assessed independently by two reviewers using the Joanna Briggs Institute critical appraisal checklist for systematic reviews and research synthesis. Quantitative data were extracted from included studies independently by the two reviewers using the standardized Joanna Briggs Institute data extraction tools. Due to the methodological heterogeneity of the included studies, a comprehensive meta-analysis for all outcomes was not possible. Meta-analysis was conducted for rehospitalization at 30, 90 and 180 days. A narrative summary of other quantitative findings was conducted. Twenty-three studies met the inclusion criteria and were included in the review. Nineteen of the studies were randomized controlled trials and four were case control studies, involving 20,997 participants in total with a mean age of 76. Meta-analysis found that transitional care significantly reduced hospital readmission rates at 30 days (odds ratio [OR] 0.75, 95% confidence intervals [CIs] 0.62-0.91, p < 0.01), 90 days (OR 0.77, 95% CIs 0.59-1.02, p = 0.04), and 180 days (OR 0.67, 95% CIs 0.46-0.99, p < 0.01). Narrative synthesis indicated little impact of transitional care on emergency department and nursing home usage, increased use of primary care/physician usage, and decreased home health care usage. Based on a review of 23 studies conducted in the USA, Hong Kong, Canada, Germany, the Netherlands, Sweden and Switzerland, we identified four major conclusions. First, transitional care reduces rehospitalization rates over time, with the largest effects seen at 30 days. Second, transitional care may increase the utilization of primary care services and thus have a favourable impact on preventative care. Third, transitional care may reduce home health usage. Fourth, transitional care interventions of one month or less appear to be as effective as longer interventions in reducing hospital usage.
Partnering with patients to promote holistic diabetes management: changing paradigms.

PubMed

Lorenzo, Lenora

2013-07-01

To provide a review of best practice for clinical management of diabetes mellitus (DM) for nurse practitioners (NPs) and accelerate incorporation of key findings into current practice. A search was conducted in Pub Med, Ovid, CINAHL, and Cochrane's Database of Systematic Reviews. There are many challenges for DM care identified in the current health system. There is a great need to change care paradigms to engage patients in partnership for enhanced management and self-management in DM. A review of the best practice evidence revealed numerous models of care, strategies, and tools available to enhance diabetes care and promote health and well-being. The primary focus of this article is to engage NP clinicians to incorporate new strategies to augment management and improve clinical outcomes. Incorporation of best practice for DM management may accelerate the paradigm shift to more patient-focused care. Engaged, informed, and activated patients along with clinicians working in partnerships may enhance clinical outcomes. ©2013 The Author ©2013 American Association of Nurse Practitioners.
The development and impact of primary health care in China from 1949 to 2015: A focused review.

PubMed

Li, Huazhang; Liu, Kun; Gu, Jianjun; Zhang, Yimin; Qiao, Yun; Sun, Xiaoming

2017-07-01

High-quality primary health care (PHC) services are associated with better health outcomes and positive health equity. Providing PHC services to all inhabitants is one of the Chinese government's health care objectives. However, an imbalance between people's increasing health needs and effective health service utilization exists in China. The objective of this review is to identify evidence for PHC development in China and to summarize the challenges as a reference for the future improvement of China's PHC system. Literature searches related to China's PHC were performed in PubMed, Web of Science, China National Knowledge Infrastructure, and Wan-fang databases. Related data were collected from the China Statistical Yearbook on Health and Family Planning 2003-2016, the China National Health Accounts Report 2015, and An Analysis Report of National Health Services Survey in China, 2013. The PHC network and the population's health have improved in China in recent years, with general practitioners as "gatekeepers" who have gradually taken the initiative to offer health services to residents. The limitation of input and shortages of resources and skilled health care providers may restrict the sustainable development of China's PHC system. Therefore, policy support from the government is necessary. Copyright © 2017 John Wiley & Sons, Ltd.
Acceptability of quality reporting and pay for performance among primary health centers in Lebanon.

PubMed

Saleh, Shadi S; Alameddine, Mohamad S; Natafgi, Nabil M

2013-01-01

Primary health care (PHC) is emphasized as the cornerstone of any health care system. Enhancing PHC performance is considered a strategy to enhance effective and equitable access to care. This study assesses the acceptability of and factors associated with quality reporting among PHC centers (PHCCs) in Lebanon. The managers of 132 Lebanese Ministry of Health PHCCs were surveyed using a cross-sectional design. Managers' willingness to report quality, participate in comparative quality assessments, and endorse pay-for-performance schemes was evaluated. Collected data were matched to the infrastructural characteristics and services database. Seventy-six percent of managers responded to the questionnaire, 93 percent of whom were willing to report clinical performance. Most expressed strong support for peer-performance comparison and pay-for-performance schemes. Willingness to report was negatively associated with the religious affiliation of centers and presence of health care facilities in the catchment area and favorably associated with use of information systems and the size of population served. The great willingness of PHCC managers to employ quality-enhancing initiatives flags a policy priority for PHC stakeholders to strengthen PHCC infrastructure and to enable reporting in an easy, standardized, and systematic way. Enhancing equity necessitates education and empowerment of managers in remote areas and those managing religiously affiliated centers.
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.
Development of a decision support tool to facilitate primary care management of patients with abnormal liver function tests without clinically apparent liver disease [HTA03/38/02]. Abnormal Liver Function Investigations Evaluation (ALFIE).

PubMed

Donnan, Peter T; McLernon, David; Steinke, Douglas; Ryder, Stephen; Roderick, Paul; Sullivan, Frank M; Rosenberg, William; Dillon, John F

2007-04-16

Liver function tests (LFTs) are routinely performed in primary care, and are often the gateway to further invasive and/or expensive investigations. Little is known of the consequences in people with an initial abnormal liver function (ALF) test in primary care and with no obvious liver disease. Further investigations may be dangerous for the patient and expensive for Health Services. The aims of this study are to determine the natural history of abnormalities in LFTs before overt liver disease presents in the population and identify those who require minimal further investigations with the potential for reduction in NHS costs. A population-based retrospective cohort study will follow up all those who have had an incident liver function test (LFT) in primary care to subsequent liver disease or mortality over a period of 15 years (approx. 2.3 million tests in 99,000 people). The study is set in Primary Care in the region of Tayside, Scotland (pop approx. 429,000) between 1989 and 2003. The target population consists of patients with no recorded clinical signs or symptoms of liver disease and registered with a GP. The health technologies being assessed are LFTs, viral and auto-antibody tests, ultrasound, CT, MRI and liver biopsy. The study will utilise the Epidemiology of Liver Disease In Tayside (ELDIT) database to determine the outcomes of liver disease. These are based on hospital admission data (Scottish Morbidity Record 1), dispensed medication records, death certificates, and examination of medical records from Tayside hospitals. A sample of patients (n = 150) with recent initial ALF tests or invitation to biopsy will complete questionnaires to obtain quality of life data and anxiety measures. Cost-effectiveness and cost utility Markov model analyses will be performed from health service and patient perspectives using standard NHS costs. The findings will also be used to develop a computerised clinical decision support tool. The results of this study will be widely disseminated to primary care, as well as G.I. hospital specialists through publications and presentations at local and national meetings and the project website. This will facilitate optimal decision-making both for the benefit of the patient and the National Health Service.
Electrocardiograms in Low-Risk Patients Undergoing an Annual Health Examination.

PubMed

Bhatia, R Sacha; Bouck, Zachary; Ivers, Noah M; Mecredy, Graham; Singh, Jasjit; Pendrith, Ciara; Ko, Dennis T; Martin, Danielle; Wijeysundera, Harindra C; Tu, Jack V; Wilson, Lynn; Wintemute, Kimberly; Dorian, Paul; Tepper, Joshua; Austin, Peter C; Glazier, Richard H; Levinson, Wendy

2017-09-01

Clinical guidelines advise against routine electrocardiograms (ECG) in low-risk, asymptomatic patients, but the frequency and impact of such ECGs are unknown. To assess the frequency of ECGs following an annual health examination (AHE) with a primary care physician among patients with no known cardiac conditions or risk factors, to explore factors predictive of receiving an ECG in this clinical scenario, and to compare downstream cardiac testing and clinical outcomes in low-risk patients who did and did not receive an ECG after their AHE. A population-based retrospective cohort study using administrative health care databases from Ontario, Canada, between 2010/2011 and 2014/2015 to identify low-risk primary care patients and to assess the subsequent outcomes of interest in this time frame. All patients 18 years or older who had no prior cardiac medical history or risk factors who received an AHE. Receipt of an ECG within 30 days of an AHE. Primary outcome was receipt of downstream cardiac testing or consultation with a cardiologist. Secondary outcomes were death, hospitalization, and revascularization at 12 months. A total of 3 629 859 adult patients had at least 1 AHE between fiscal years 2010/2011 and 2014/2015. Of these patients, 21.5% had an ECG within 30 days after an AHE. The proportion of patients receiving an ECG after an AHE varied from 1.8% to 76.1% among 679 primary care practices (coefficient of quartile dispersion [CQD], 0.50) and from 1.1% to 94.9% among 8036 primary care physicians (CQD, 0.54). Patients who had an ECG were significantly more likely to receive additional cardiac tests, visits, or procedures than those who did not (odds ratio [OR], 5.14; 95% CI, 5.07-5.21; P < .001). The rates of death (0.19% vs 0.16%), cardiac-related hospitalizations (0.46% vs 0.12%), and coronary revascularizations (0.20% vs 0.04%) were low in both the ECG and non-ECG cohorts. Despite recommendations to the contrary, ECG testing after an AHE is relatively common, with significant variation among primary care physicians. Routine ECG testing seems to increase risk for a subsequent cardiology testing and consultation cascade, even though the overall cardiac event rate in both groups was very low.
Pharmaceutical Services in Primary Health Care: are pharmacists and users on the same page?

PubMed

Luz, Tatiana Chama Borges; Costa, Maria Emília Silva de Souza; Portes, Daniela Santana; Santos, Lucas Barbi Costa E; Sousa, Samuel Rodrigues Almeida E; Luiza, Vera Lucia

2017-08-01

This study investigated structural and organizational characteristics of the Pharmaceutical Services based on Primary Health Care (PHCPS) from the viewpoints of users and pharmacists. A mixed method design was applied, combining one-to-one semi-structured interviews with four pharmacists in charge of five public dispensing facilities and 69 users, with a secondary database analysis. Data were collected from February to August 2014 in Divinópolis, a municipality in Minas Gerais State. PHCPS were similar in terms of general activities performed and staff profile and background. While users were concerned about medicines' availability and improvements related to the PHCPS' conveniences and personnel, pharmacists pointed out problems regarding infrastructure to storage. Despite most users had low information on how to use their medicines, no pharmacists declared to participate in medicines dispensing activities. There was a low match between users and pharmacists viewpoints and advantages for concentrate medicines dispensing in a smaller number of facilities were not clear.
Health Care in Gulf Cooperation Council Countries: A Review of Challenges and Opportunities

PubMed Central

Khoja, Tawfiq; Rawaf, Salman; Rawaf, David; Nanji, Kashmira; Hamad, Aisha

2017-01-01

This study was undertaken to review the health care status in the Gulf Cooperation Council (GCC) member states, and explore current challenges and future opportunities. Available data was acquired using databases including PubMed, Embase, and Cochrane Library. The data gathered was then combined and the expert authors in the field discussed and propose strategies to overcome the challenges. There is an increase in both population and health care needs of GCC States citizens and migrant workers. The huge emigrant population challenges the capability of the already limited available health care resources. The region is faced with a quadruple disease burden that includes communicable and non-communicable diseases, mental health issues and accidental injuries. Recent advances in technology have made breakthroughs in diagnosis and treatment modalities but with an increase in overall health care cost. Innovative and cost-effective strategies are required to cater the health care needs of people living in the GCC states. Policy makers should emphasize the need to prioritize and strengthen primary care as a matter of urgency. PMID:29062618
Health Care in Gulf Cooperation Council Countries: A Review of Challenges and Opportunities.

PubMed

Khoja, Tawfiq; Rawaf, Salman; Qidwai, Waris; Rawaf, David; Nanji, Kashmira; Hamad, Aisha

2017-08-21

This study was undertaken to review the health care status in the Gulf Cooperation Council (GCC) member states, and explore current challenges and future opportunities. Available data was acquired using databases including PubMed, Embase, and Cochrane Library. The data gathered was then combined and the expert authors in the field discussed and propose strategies to overcome the challenges. There is an increase in both population and health care needs of GCC States citizens and migrant workers. The huge emigrant population challenges the capability of the already limited available health care resources. The region is faced with a quadruple disease burden that includes communicable and non-communicable diseases, mental health issues and accidental injuries. Recent advances in technology have made breakthroughs in diagnosis and treatment modalities but with an increase in overall health care cost. Innovative and cost-effective strategies are required to cater the health care needs of people living in the GCC states. Policy makers should emphasize the need to prioritize and strengthen primary care as a matter of urgency.
Healthcare databases in Europe for studying medicine use and safety during pregnancy.

PubMed

Charlton, Rachel A; Neville, Amanda J; Jordan, Sue; Pierini, Anna; Damase-Michel, Christine; Klungsøyr, Kari; Andersen, Anne-Marie Nybo; Hansen, Anne Vinkel; Gini, Rosa; Bos, Jens H J; Puccini, Aurora; Hurault-Delarue, Caroline; Brooks, Caroline J; de Jong-van den Berg, Lolkje T W; de Vries, Corinne S

2014-06-01

The aim of this study was to describe a number of electronic healthcare databases in Europe in terms of the population covered, the source of the data captured and the availability of data on key variables required for evaluating medicine use and medicine safety during pregnancy. A sample of electronic healthcare databases that captured pregnancies and prescription data was selected on the basis of contacts within the EUROCAT network. For each participating database, a database inventory was completed. Eight databases were included, and the total population covered was 25 million. All databases recorded live births, seven captured stillbirths and five had full data available on spontaneous pregnancy losses and induced terminations. In six databases, data were usually available to determine the date of the woman's last menstrual period, whereas in the remainder, algorithms were needed to establish a best estimate for at least some pregnancies. In seven databases, it was possible to use data recorded in the databases to identify pregnancies where the offspring had a congenital anomaly. Information on confounding variables was more commonly available in databases capturing data recorded by primary-care practitioners. All databases captured maternal co-prescribing and a measure of socioeconomic status. This study suggests that within Europe, electronic healthcare databases may be valuable sources of data for evaluating medicine use and safety during pregnancy. The suitability of a particular database, however, will depend on the research question, the type of medicine to be evaluated, the prevalence of its use and any adverse outcomes of interest. © 2014 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons, Ltd. © 2014 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons, Ltd.
Relation between diabetes, metformin treatment and the occurrence of malignancies in a Belgian primary care setting.

PubMed

Geraldine, Ngwana; Marc, Aerts; Carla, Truyers; Chantal, Mathieu; Stefaan, Bartholomeeusen; Welcome, Wami; Frank, Buntinx

2012-08-01

Associations between type 2 diabetic patients and a higher risk of developing cancer have been reported worldwide. Recently, a protective effect of metformin has been described. To examine in the Belgian primary care population the relation between presence of type 2 diabetes with and without metformin treatment and the occurrence of malignancies. Retrospective cohort study, based on the Intego database, an ongoing Belgian general practice-based morbidity registry, covering 90 general practitioners and including about 1.5 million patient-years between 1994 and 2008. Cox proportional hazard analysis comparing emergence of malignancy in patients with and without type 2 diabetes, and among patients with diabetes comparing emergence of malignancy in those treated with various antidiabetic drugs. Malignancies occurred more in type 2 diabetic patients compared to non-diabetic controls (HR=1.84; 95% CI=1.51-2.24), adjusted for age, gender and weight. Treatment with both metformin and 'other' antidiabetic agents was related to decreased cancer risk (HR=0.24 and 0.22) compared to diet only in men but not in women. In this Belgian primary care setting, diabetic patients have higher cancer prevalences than non-diabetic patients. Moreover, in diabetic men, not only metformin but also other antidiabetic agents were associated with lower cancer risks. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Prevalence and patterns of antidepressant switching amongst primary care patients in the UK.

PubMed

Mars, Becky; Heron, Jon; Gunnell, David; Martin, Richard M; Thomas, Kyla H; Kessler, David

2017-05-01

Non-response to antidepressant treatment is a substantial problem in primary care, and many patients with depression require additional second-line treatments. This study aimed to examine the prevalence and patterns of antidepressant switching in the UK, and identify associated demographic and clinical factors. Cohort analysis of antidepressant prescribing data from the Clinical Practice Research Datalink, a large, anonymised UK primary care database. The sample included 262,844 patients who initiated antidepressant therapy between 1 January 2005 and 31 June 2011. 9.3% of patients switched to a different antidepressant product, with most switches (60%) occurring within 8 weeks of the index date. The proportion switching was similar for selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and other antidepressants (9.3%, 9.8% and 9.2%, respectively). Most switches were to an SSRI (64.5%), and this was the preferred option regardless of initial antidepressant class. Factors predictive of switching included male gender, age, and history of self-harm and psychiatric illness. Over one in every 11 patients who initiates antidepressant therapy will switch medication, suggesting that initial antidepressant treatment has been unsatisfactory. Evidence to guide choice of second-line treatment for individual patients is currently limited. Additional research comparing different pharmacological and psychological second-line treatment strategies is required in order to inform guidelines and improve patient outcomes.
The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review.

PubMed

Lebeau, Jean-Pierre; Cadwallader, Jean-Sébastien; Aubin-Auger, Isabelle; Mercier, Alain; Pasquet, Thomas; Rusch, Emmanuel; Hendrickx, Kristin; Vermeire, Etienne

2014-07-02

Therapeutic inertia has been defined as the failure of health-care provider to initiate or intensify therapy when therapeutic goals are not reached. It is regarded as a major cause of uncontrolled hypertension. The exploration of its causes and the interventions to reduce it are plagued by unclear conceptualizations and hypothesized mechanisms. We therefore systematically searched the literature for definitions and discussions on the concept of therapeutic inertia in hypertension in primary care, to try and form an operational definition. A systematic review of all types of publications related to clinical inertia in hypertension was performed. Medline, EMbase, PsycInfo, the Cochrane library and databases, BDSP, CRD and NGC were searched from the start of their databases to June 2013. Articles were selected independently by two authors on the basis of their conceptual content, without other eligibility criteria or formal quality appraisal. Qualitative data were extracted independently by two teams of authors. Data were analyzed using a constant comparative qualitative method. The final selection included 89 articles. 112 codes were grouped in 4 categories: terms and definitions (semantics), "who" (physician, patient or system), "how and why" (mechanisms and reasons), and "appropriateness". Regarding each of these categories, a number of contradictory assertions were found, most of them relying on little or no empirical data. Overall, the limits of what should be considered as inertia were not clear. A number of authors insisted that what was considered deleterious inertia might in fact be appropriate care, depending on the situation. Our data analysis revealed a major lack of conceptualization of therapeutic inertia in hypertension and important discrepancies regarding its possible causes, mechanisms and outcomes. The concept should be split in two parts: appropriate inaction and inappropriate inertia. The development of consensual and operational definitions relying on empirical data and the exploration of the intimate mechanisms that underlie these behaviors are now needed.
The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review

PubMed Central

2014-01-01

Background Therapeutic inertia has been defined as the failure of health-care provider to initiate or intensify therapy when therapeutic goals are not reached. It is regarded as a major cause of uncontrolled hypertension. The exploration of its causes and the interventions to reduce it are plagued by unclear conceptualizations and hypothesized mechanisms. We therefore systematically searched the literature for definitions and discussions on the concept of therapeutic inertia in hypertension in primary care, to try and form an operational definition. Methods A systematic review of all types of publications related to clinical inertia in hypertension was performed. Medline, EMbase, PsycInfo, the Cochrane library and databases, BDSP, CRD and NGC were searched from the start of their databases to June 2013. Articles were selected independently by two authors on the basis of their conceptual content, without other eligibility criteria or formal quality appraisal. Qualitative data were extracted independently by two teams of authors. Data were analyzed using a constant comparative qualitative method. Results The final selection included 89 articles. 112 codes were grouped in 4 categories: terms and definitions (semantics), “who” (physician, patient or system), “how and why” (mechanisms and reasons), and “appropriateness”. Regarding each of these categories, a number of contradictory assertions were found, most of them relying on little or no empirical data. Overall, the limits of what should be considered as inertia were not clear. A number of authors insisted that what was considered deleterious inertia might in fact be appropriate care, depending on the situation. Conclusions Our data analysis revealed a major lack of conceptualization of therapeutic inertia in hypertension and important discrepancies regarding its possible causes, mechanisms and outcomes. The concept should be split in two parts: appropriate inaction and inappropriate inertia. The development of consensual and operational definitions relying on empirical data and the exploration of the intimate mechanisms that underlie these behaviors are now needed. PMID:24989986
Evaluating the effectiveness, impact and safety of live attenuated and seasonal inactivated influenza vaccination: protocol for the Seasonal Influenza Vaccination Effectiveness II (SIVE II) study.

PubMed

Simpson, Colin R; Lone, Nazir I; Kavanagh, Kimberley; Robertson, Chris; McMenamin, Jim; von Wissmann, Beatrix; Vasileiou, Eleftheria; Butler, Chris; Ritchie, Lewis D; Gunson, Rory; Schwarze, Jürgen; Sheikh, Aziz

2017-02-28

Seasonal (inactivated) influenza vaccination is recommended for all individuals aged 65+ and in individuals under 65 who are at an increased risk of complications of influenza infection, for example, people with asthma . Live attenuated influenza vaccine (LAIV) was recommended for children as they are thought to be responsible for much of the transmission of influenza to the populations at risk of serious complications from influenza. A phased roll-out of the LAIV pilot programme began in 2013/2014. There is limited evidence for vaccine effectiveness (VE) in the populations targeted for influenza vaccination. The aim of this study is to examine the safety and effectiveness of the live attenuated seasonal influenza vaccine programme in children and the inactivated seasonal influenza vaccination programme among different age and at-risk groups of people. Test negative and cohort study designs will be used to estimate VE. A primary care database covering 1.25 million people in Scotland for the period 2000/2001 to 2015/2016 will be linked to the Scottish Immunisation Recall Service (SIRS), Health Protection Scotland virology database, admissions to Scottish hospitals and the Scottish death register. Vaccination status (including LAIV uptake) will be determined from the primary care and SIRS database. The primary outcome will be influenza-positive real-time PCR tests carried out in sentinel general practices and other healthcare settings. Secondary outcomes include influenza-like illness and asthma-related general practice consultations, hospitalisations and death. An instrumental variable analysis will be carried out to account for confounding. Self-controlled study designs will be used to estimate the risk of adverse events associated with influenza vaccination. We obtained approval from the National Research Ethics Service Committee, West Midlands-Edgbaston. The study findings will be presented at international conferences and published in peer-reviewed journals. ISRCTN88072400; Pre-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
The impact of dementia on influenza vaccination uptake in community and care home residents.

PubMed

Shah, Sunil M; Carey, Iain M; Harris, Tess; DeWilde, Stephen; Cook, Derek G

2012-01-01

Influenza vaccination is recommended for older people irrespective of cognitive decline or residential setting. To examine the effect of dementia diagnosis on flu vaccination uptake in community and care home residents in England and Wales. Retrospective analysis of a primary care database with 378,462 community and 9,106 care (nursing and residential) home residents aged 65-104 in 2008-09. Predictors of vaccine uptake were examined adjusted for age, sex, area deprivation and major chronic diseases. Age and sex standardised uptake of influenza vaccine was 74.7% (95% CI: 73.7-75.8%) in community patients without dementia, 71.4% (69.3-73.5%) in community patients with dementia, 80.5% (78.9-82.2%) in care home patients without dementia and 83.3% (81.4-85.3%) in care home patients with dementia. In a fully adjusted model, compared with community patients without dementia, patients with dementia in the community were less likely to receive vaccination (RR: 0.96, 95% CI: 0.94-0.97) while care home patients with (RR: 1.06, 1.03-1.09) and without (RR: 1.03, 1.01-1.05) dementia were more likely to receive vaccination. Area deprivation and chronic diseases were, respectively, negative and positive predictors of uptake. Lower influenza vaccine uptake among community patients with dementia, compared with care home residents, suggests organisational barriers to community uptake but high uptake among patients with dementia in care homes does not suggest concern over informed consent acts as a barrier. Primary care for community patients with dementia needs to ensure that they receive all appropriate preventive interventions.

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