Alimena, Stephanie; Air, Mary E; Gribbin, Caitlin; Manejias, Elizabeth
This study examines the current utilization of primary and preventive health care services among dancers in order to assess their self-reported primary care needs. Participants were 37 dancers from a variety of dance backgrounds who presented for a free dancer health screening in a large US metropolitan area (30 females, 7 males; mean age: 27.5 ± 7.4 years; age range: 19 to 49 years; mean years of professional dancing: 6.4 ± 5.4 years). Dancers were screened for use of primary care, mental health, and women's health resources using the Health Screen for Professional Dancers developed by the Task Force on Dancer Health. Most dancers had health insurance (62.2%), but within the last 2 years, only approximately half of them (54.1%) reported having a physical examination by a physician. Within the last year, 54.1% of dancers had had a dental check-up, and 56.7% of female dancers received gynecologic care. Thirty percent of female participants indicated irregular menstrual cycles, 16.7% had never been to a gynecologist, and 16.7% were taking birth control. Utilization of calcium and vitamin D supplementation was 27.0% and 29.7%, respectively, and 73.0% were interested in nutritional counseling. A high rate of psychological fatigue and sleep deprivation was found (35.1%), along with a concomitant high rate of self-reported need for mental health counseling (29.7%). Cigarette and recreational drug use was low (5.4% and 5.4%); however, 32.4% engaged in binge drinking within the last year (based on the CDC definition). These findings indicate that dancers infrequently access primary care services, despite high self-reported need for nutritional, mental, and menstrual health counseling and treatment. More studies are warranted to understand dancers' primary health care seeking behavior.
Hollis, Jack F.; Polen, Michael R.; Lichtenstein, Edward; Whitlock, Evelyn P.
Investigated the tobacco-related attitudes, behaviors, and needs of smoking and nonsmoking teens being seen for routine primary care, identifying tobacco use predictors. Most teens approached were willing to receive tobacco and diet interventions. Smoking predictors included older age, lower educational aspirations, having parents or friends who…
Tillison, Ashley Simone; Avery, Ann Keltner
Since 2006, numerous testing initiatives have been launched across the United States to increase the number of individuals who know their HIV status. These initiatives are often venue based and reported in a variety of settings. However, the effectiveness of these initiatives has not been evaluated to determine if patients were identified earlier in the course of disease or would not have been otherwise tested. In 2010, a publicly funded teaching hospital implemented an electronic medical record prompt to improve the rate of routine HIV screening and diagnosis, focusing on primary care office visits. Both sex and CD4 count were found to be significantly related to being newly diagnosed after the intervention. Routine testing in primary care is an effective strategy to diagnose patients earlier in disease progression, particularly men who might otherwise not be tested and thus would remain undiagnosed until developing symptoms from advanced disease.
Phillips, Kelly-Anne; Steel, Emma J; Collins, Ian; Emery, Jon; Pirotta, Marie; Mann, G Bruce; Butow, Phyllis; Hopper, John L; Trainer, Alison; Moreton, Jane; Antoniou, Antonis C; Cuzick, Jack; Keogh, Louise
To capitalise on advances in breast cancer prevention, all women would need to have their breast cancer risk formally assessed. With ~85% of Australians attending primary care clinics at least once a year, primary care is an opportune location for formal breast cancer risk assessment and management. This study assessed the current practice and needs of primary care clinicians regarding assessment and management of breast cancer risk. Two facilitated focus group discussions were held with 17 primary care clinicians (12 GPs and 5 practice nurses (PNs)) as part of a larger needs assessment. Primary care clinicians viewed assessment and management of cardiovascular risk as an intrinsic, expected part of their role, often triggered by practice software prompts and facilitated by use of an online tool. Conversely, assessment of breast cancer risk was not routine and was generally patient- (not clinician-) initiated, and risk management (apart from routine screening) was considered outside the primary care domain. Clinicians suggested that routine assessment and management of breast cancer risk might be achieved if it were widely endorsed as within the remit of primary care and supported by an online risk-assessment and decision aid tool that was integrated into primary care software. This study identified several key issues that would need to be addressed to facilitate the transition to routine assessment and management of breast cancer risk in primary care, based largely on the model used for cardiovascular disease.
Vest, Bonnie M; Hall, Victoria M; Kahn, Linda S; Heider, Arvela R; Maloney, Nancy; Singh, Ranjit
Aims The purpose of this qualitative evaluation was to explore the experience of implementing routine telemonitoring (TM) in real-world primary care settings from the perspective of those delivering the intervention; namely the TM staff, and report on lessons learned that could inform future projects of this type.
Background In primary care, patients with multiple chronic conditions are the rule rather than the exception. The Chronic Care Model (CCM) is an evidence-based framework for improving chronic illness care, but little is known about the extent to which it has been implemented in routine primary care. The aim of this study was to describe how multimorbid older patients assess the routine chronic care they receive in primary care practices in Germany, and to explore the extent to which factors at both the practice and patient level determine their views. Methods This cross-sectional study used baseline data from an observational cohort study involving 158 general practitioners (GP) and 3189 multimorbid patients. Standardized questionnaires were employed to collect data, and the Patient Assessment of Chronic Illness Care (PACIC) questionnaire used to assess the quality of care received. Multilevel hierarchical modeling was used to identify any existing association between the dependent variable, PACIC, and independent variables at the patient level (socio-economic factors, weighted count of chronic conditions, instrumental activities of daily living, health-related quality of life, graded chronic pain, no. of contacts with GP, existence of a disease management program (DMP) disease, self-efficacy, and social support) and the practice level (age and sex of GP, years in current practice, size and type of practice). Results The overall mean PACIC score was 2.4 (SD 0.8), with the mean subscale scores ranging from 2.0 (SD 1.0, subscale goal setting/tailoring) to 3.5 (SD 0.7, delivery system design). At the patient level, higher PACIC scores were associated with a DMP disease, more frequent GP contacts, higher social support, and higher autonomy of past occupation. At the practice level, solo practices were associated with higher PACIC values than other types of practice. Conclusions This study shows that from the perspective of multimorbid patients receiving care in German
Background The objective of this study is to perform an independent evaluation of the feasibility and effectiveness of an educational programme for the primary prevention of type 2 diabetes (DM2) in high risk populations in primary care settings, implanted within the Basque Health Service - Osakidetza. Methods/design This is a prospective phase IV cluster clinical trial conducted under routine conditions in 14 primary health care centres of Osakidetza, randomly assigned to an intervention or control group. We will recruit a total sample of 1089 individuals, aged between 45 and 70 years old, without diabetes but at high risk of developing the condition (Finnish Diabetes Risk Score, FINDRISC ≥ 14) and follow them up for 2 years. Primary health care nursing teams of the intervention centres will implement DE-PLAN, a structured educational intervention program focused on changing healthy lifestyles (diet and physical activity); while the patients in the control centres will receive the usual care for the prevention and treatment of DM2 currently provided in Osakidetza. The effectiveness attributable to the programme will be assessed by comparing the changes observed in patients exposed to the intervention and those in the control group, with respect to the risk of developing DM2 and lifestyle habits. In terms of feasibility, we will assess indicators of population coverage and programme implementation. Discussion The aim of this study is to provide the scientific basis for disseminate the programme to the remaining primary health centres in Osakidetza, as a novel way of addressing prevention of DM2. The study design will enable us to gather information on the effectiveness of the intervention as well as the feasibility of implementing it in routine practice. Trial registration ClinicalTrials.gov NCT01365013 PMID:23158830
Sherman, Scott E; Fotiades, John; Rubenstein, Lisa V; Gilman, Stuart C; Vivell, Susan; Chaney, Edmund; Yano, Elizabeth M; Felker, Bradford
Although health care organizations seeking to improve quality often must change the system for delivering care, there is little available evidence on how to educate staff and providers about this change. As part of a 2002-2003 Veterans Health Administration multisite project using collaborative care to improve the management of depression, the authors implemented the Translating Initiatives for Depression into Effective Solutions (TIDES) program. Five steps were followed for teaching systems-based practice: (1) determine providers' educational needs (through administrative data, expert opinion, and provider discussion), (2) develop educational materials (based on needs assessed), (3) help each of seven sites develop an educational intervention, (4) implement the intervention, and (5) monitor the intervention's effectiveness. Sites relied primarily on passive educational strategies. There was variable implementation of the different components (e.g., lecture, educational outreach). No site chose to write up its education plan, as was suggested. The authors thus suggest that the educational model was successful at identifying providers' needs and creating appropriate materials, because the program was not advertised in other ways and because almost all providers referred patients to the program. However, the educational model was only partially successful at getting sites to develop and implement an educational plan, although provider behavior did change. Overall, the program was somewhat effective at teaching systems-based practice. The authors believe the best way to enhance effectiveness is to build education into the system rather than rely on a separate system for education.
Lillrank, Paul; Liukko, Matti
Quality management methods have been introduced into health care with variable success. Industrial approaches, such as standardization, are not always applicable professional services, because of fundamental differences in conceptions of aims and the predictability of the results of action. Processes in health care can be classified into standard, routine and non-routine depending on the level of repetition and amount of variation, variety and uncertainty. Quality problems are different in each type: standard processes may produce deviations from targets, routines errors in classification, and non-routines failures in interpretation. Different management approaches for each type are discussed. A metaphor to assist discussion, The Broom, is introduced.
Closser, Svea; Cox, Kelly; Parris, Thomas M.; Landis, R. Matthew; Justice, Judith; Gopinath, Ranjani; Maes, Kenneth; Banteyerga Amaha, Hailom; Mohammed, Ismaila Zango; Dukku, Aminu Mohammed; Omidian, Patricia A.; Varley, Emma; Tedoff, Pauley; Koon, Adam D.; Nyirazinyoye, Laetitia; Luck, Matthew A.; Pont, W. Frank; Neergheen, Vanessa; Rosenthal, Anat; Nsubuga, Peter; Thacker, Naveen; Jooma, Rashid; Nuttall, Elizabeth
Background. After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC). Methods. Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review. Results. Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year. Conclusions. Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts. PMID:24690667
Background We have previously demonstrated that routinely collected primary care data can be used to identify potential participants for trials in depression . Here we demonstrate how patients with psychotic disorders can be identified from primary care records for potential inclusion in a cohort study. We discuss the strengths and limitations of this approach; assess its potential value and report challenges encountered. Methods We designed an algorithm with which we searched for patients with a lifetime diagnosis of psychotic disorders within the Secure Anonymised Information Linkage (SAIL) database of routinely collected health data. The algorithm was validated against the "gold standard" of a well established operational criteria checklist for psychotic and affective illness (OPCRIT). Case notes of 100 patients from a community mental health team (CMHT) in Swansea were studied of whom 80 had matched GP records. Results The algorithm had favourable test characteristics, with a very good ability to detect patients with psychotic disorders (sensitivity > 0.7) and an excellent ability not to falsely identify patients with psychotic disorders (specificity > 0.9). Conclusions With certain limitations our algorithm can be used to search the general practice data and reliably identify patients with psychotic disorders. This may be useful in identifying candidates for potential inclusion in cohort studies. PMID:22333117
Sicras-Mainar, Antoni; Rejas, Javier; Navarro, Ruth; Blanca, Milagrosa; Morcillo, Ángela; Larios, Raquel; Velasco, Soledad; Villarroya, Carme
Introduction The objective of this study was to analyze health care and non-health care resource utilization under routine medical practice in a primary care setting claims database and to estimate the incremental average cost per patient per year of fibromyalgia syndrome (FMS) compared with a reference population. Methods A 12-month cross-sectional and retrospective study was completed using computerized medical records from a health provider database. Analyses were conducted from the perspective of the provider and from the viewpoint of society. Health care and non-health care resource utilization included drugs, complementary tests, all types of medical visits, referrals, hospitalizations, sick leave, and early retirement because of disability due to FMS. Patients with a diagnosis of FMS in accordance with ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th revision) criteria were included in the analysis if they had at least one claim for FMS during the 12 months prior to the end of May 2007. A non-FMS comparison group was also created with the remaining subjects. Results Of the 63,526 patients recruited for the study, 1,081 (1.7%) (96.7% of whom were women, 54.2 [10.1] years old) met the criteria for FMS. After an adjustment for age and gender, FMS subjects used significantly more health care resources than the reference population and had more sick leave and the percentage of subjects with premature retirement was also significantly higher (P < 0.001 in all cases). As a result, FMS subjects showed an incremental adjusted per-patient per-year total cost of €5,010 (95% confidence interval [CI] 3,494 to 6,076, +153%, P < 0.001) on average compared with non-FMS subjects. Significantly higher differences were observed in both health care and non-health care adjusted costs: €614 (404 to 823, +66%) and €4,394 (3,373 to 5,420, +189%), respectively (P < 0.001 in both cases). Annual drug expenditure per patient on
Butler, Christopher C.; Simpson, Sharon; Wood, Fiona
Objective Near-patient tests are promoted for guiding management of common infections in primary care with a view to enhancing the effectiveness of prescribing decisions and containing antimicrobial resistance. Changes in clinical practice should be based on appraisals of the factors that might influence change, viewed from the perspective of those expected to implement the change. We therefore explored the views of general practitioners concerning the possible introduction of near-patient tests for managing common infections. Design Qualitative semi-structured interview study. Interviews were recorded and analysed using thematic content analysis. Setting General practices in south-east Wales, UK. Subjects A total of 26 general practitioners (GPs) from high fluroquinolone antibiotics prescribing practices and 14 GPs from practices that prescribed fluroquinolones close to the south-east Wales mean. Results There was strong enthusiasm for a hypothetical near-patient, finger-prick blood tests that could distinguish viral from bacterial infections. Many GPs emphasized that such tests would be valuable in “selling” decisions not to prescribe antibiotics to patients. Concerns included limited additional useful information to guide prescribing above clinical diagnosis alone, that patients might deteriorate even if the tests correctly identified a viral aetiology, and that GPs would need to be convinced by research evidence supporting uptake. Several indicated that tests would be useful only for a limited number of patients and they were concerned by time pressures, apparatus maintenance and quality control, cost, and possible objections from patients, especially children. Conclusions Despite GP enthusiasm for the concept of a rapid test to distinguish viral from bacterial infection, strategies to promote uptake would be enhanced if concerns were addressed regarding the importance and feasibility of such tests in daily practice. PMID:18297558
Pinnock, Hilary; Fletcher, Monica; Holmes, Steve; Keeley, Duncan; Leyshon, Jane; Price, David; Russell, Richard; Versnel, Jenny; Wagstaff, Bronwen
Globally, asthma morbidity remains unacceptably high. If outcomes are to be improved, it is crucial that routine review consultations in primary care are performed to a high standard. Key components of a review include: * Assessment of control using specific morbidity questions to elucidate the presence of symptoms, in conjunction with the frequency of use of short-acting bronchodilators and any recent history of acute attacks * After consideration of the diagnosis, and an assessment of compliance, inhaler technique, smoking status, triggers, and rhinitis, identification of poor control should result in a step-up of treatment in accordance with evidence-based guideline recommendations * Discussion should address understanding of the condition, patient-centred management goals and attitudes to regular treatment, and should include personalised self-management education Regular review of people with asthma coupled with provision of self-management education improves outcomes. Underpinned by a theoretical framework integrating professional reviews and patient self-care we discuss the practical barriers to implementing guided selfmanagement in routine clinical practice.
Chatterjee, Sudipto; Chowdhary, Neerja; Pednekar, Sulochana; Cohen, Alex; Andrew, Gracy; Andrew, Gracy; Araya, Ricardo; Simon, Gregory; King, Michael; Telles, Shirley; Verdeli, Helena; Clougherty, Kathleen; Kirkwood, Betty; Patel, Vikram
Common mental disorders, such as depression and anxiety, pose a major public health burden in developing countries. Although these disorders are thought to be best managed in primary care settings, there is a dearth of evidence about how this can be achieved in low resource settings. The MANAS project is an attempt to integrate an evidence based package of treatments into routine public and private primary care settings in Goa, India. Before initiating the trial, we carried out extensive preparatory work, over a period of 15 months, to examine the feasibility and acceptability of the planned intervention. This paper describes the systematic development and evaluation of the intervention through this preparatory phase. The preparatory stage, which was implemented in three phases, utilized quantitative and qualitative methods to inform our understanding of the potential problems and possible solutions in implementing the trial and led to critical modifications of the original intervention plan. Investing in systematic formative work prior to conducting expensive trials of the effectiveness of complex interventions is a useful exercise which potentially improves the likelihood of a positive result of such trials.
Parker, Sharon M; Litt, John; van Driel, Mieke; Russell, Grant; Mazza, Danielle; Jayasinghe, Upali W; Del Mar, Chris; Lloyd, Jane; Smith, Jane; Zwar, Nicholas; Taylor, Richard; Powell Davies, Gawaine
Objective To evaluate an intervention to improve implementation of guidelines for the prevention of chronic vascular disease. Setting 32 urban general practices in 4 Australian states. Randomisation Stratified randomisation of practices. Participants 122 general practitioners (GPs) and practice nurses (PNs) were recruited at baseline and 97 continued to 12 months. 21 848 patient records were audited for those aged 40–69 years who attended the practice in the previous 12 months without heart disease, stroke, diabetes, chronic renal disease, cognitive impairment or severe mental illness. Intervention The practice level intervention over 6 months included small group training of practice staff, feedback on audited performance, practice facilitation visits and provision of patient education and referral information. Outcome measures Primary: 1. Change in proportion of patients aged 40–69 years with smoking status, alcohol intake, body mass index (BMI), waist circumference (WC), blood pressure (BP) recorded and for those aged 45–69 years with lipids, fasting blood glucose and cardiovascular risk in the medical record. 2. Change in the level of risk for each factor. Secondary change in self-reported frequency and confidence of GPs and PNs in assessment. Results Risk recording improved in the intervention but not the control group for WC (OR 2.52 (95% CI 1.30 to 4.91)), alcohol consumption (OR 2.19 (CI 1.04 to 4.64)), smoking status (OR 2.24 (1.17 to 4.29)) and cardiovascular risk (OR 1.50 (1.04 to 2.18)). There was no change in recording of BP, lipids, glucose or BMI and no significant change in the level of risk factors based on audit data. The confidence but not reported practices of GPs and PNs in the intervention group improved in the assessment of some risk factors. Conclusions This intervention was associated with improved recording of some risk factors but no change in the level of risk at the follow-up audit. Trial registration number
Background Neuropathic pain (NeP) is a common symptom of a group of a variety of conditions, including diabetic neuropathy, trigeminal neuralgia, or postherpetic neuralgia. Prevalence of NeP has been estimated to range between 5-7.5%, and produces up to 25% of pain clinics consultations. Due to its severity, chronic evolution, and associated co-morbidities, NeP has an important individual and social impact. The objective was to analyze the effect of pregabalin (PGB) on pain alleviation and longitudinal health and non-health resources utilization and derived costs in peripheral refractory NeP in routine medical practice in primary care settings (PCS) in Spain. Methods Subjects from PCS were older than 18 years, with peripheral NeP (diabetic neuropathy, post-herpetic neuralgia or trigeminal neuralgia), refractory to at least one previous analgesic, and included in a prospective, real world, and 12-week two-visit cost-of-illness study. Measurement of resources utilization included both direct healthcare and indirect expenditures. Pain severity was measured by the Short Form-McGill Pain Questionnaire (SF-MPQ). Results One-thousand-three-hundred-fifty-four PGB-naive patients [58.8% women, 59.5 (12.7) years old] were found eligible for this secondary analysis: 598 (44%) switched from previous therapy to PGB given in monotherapy (PGBm), 589 (44%) received PGB as add-on therapy (PGB add-on), and 167 (12%) patients changed previous treatments to others different than PGB (non-PGB). Reductions of pain severity were higher in both PGBm and PGB add-on groups (54% and 51%, respectively) than in non-PGB group (34%), p < 0.001. Incremental drug costs, particularly in PGB subgroups [€34.6 (80.3), €160.7 (123.9) and €154.5 (133.0), for non-PGB, PGBm and PGBadd-on, respectively (p < 0.001)], were off-set by higher significant reductions in all other components of health costs yielding to a greater total cost reductions: -€1,045.3 (1,989.6),-€1,312.9 (1,543.0), and -€1
Pelzl, Steffen; Szecsenyi, Joachim; Laux, Gunter
Objectives Antibiotic overprescribing in primary care has major impacts on the development of antibiotic resistance. The objective of this study is to provide insight in antibiotics prescriptions for patients suffering from cough, acute bronchitis or community acquired pneumonia in primary care. Methods Data from 2009 to 2013 of electronic health records of 12,880 patients in Germany were obtained from a research database. The prescription of antibiotics for acute lower respiratory tract infections was compared to the national S3 guideline cough from the German Society of General Practitioners and Family Medicine. Results Antibiotics were prescribed in 41% of consultations. General practitioners’ decision of whether or not to prescribe an antibiotic was congruent with the guideline in 52% of consultations and the antibiotic choice congruence was 51% of antibiotic prescriptions. Hence, a congruent prescribing decision and a prescription of recommendation was found in only 25% of antibiotic prescriptions. Split by diagnosis we found that around three quarters of antibiotics prescribed for cough (73%) and acute bronchitis (78%) were not congruent to the guidelines. In contrast to that around one quarter of antibiotics prescribed for community acquired pneumonia (28%) were not congruent to the guidelines. Conclusions Our results show that there is a big gap between guideline recommendation and actual prescribing, in the decision to prescribe and the choice of antibiotic agent. This gap could be closed by periodic quality circles on antibiotic prescribing for GPs. PMID:28350820
Peters, Michele; Crocker, Helen; Jenkinson, Crispin; Doll, Helen; Fitzpatrick, Ray
Objectives To evaluate the feasibility of using patient-reported outcome measures (PROMs) for long-term conditions (LTCs) in primary care. Design A cohort postal survey conducted from September 2010 to April 2012. Setting Primary care practices (n=33) in London and the North-West of England. Participants 4484 patients with a diagnosis of asthma, chronic obstructive pulmonary disease, diabetes, epilepsy, heart failure or stroke were sent a survey at baseline. Main outcome The main outcome was to evaluate the feasibility of and the recruitment strategies for collecting PROMs data in LTCs by assessing the response rates for the baseline and follow-up surveys. Secondary outcomes were the evaluation of change scores of the EQ-5D index and visual analogue scale (VAS) between baseline and follow-up surveys. Results The baseline survey achieved a response rate of 38.4% (n=1721/4485) and at follow-up 71.5% (n=1136/1589). Response rates varied by LTC. Little change was found in health-related quality of life for the total sample (−0.001 for the EQ-5D index score and 0.12 for the EQ-5D VAS) between patients responding to both the baseline and follow-up surveys. Conclusions The response rate to the baseline survey was similar to that of other general practice surveys. Current UK policy aims to assess health service performance in LTCs by means of using PROMs. It thus would be desirable to improve response rates by making the invitation to self-reports of health-related quality of life more engaging for patients. Results on the EQ-5D score raise questions about optimal indicators for LTCs and appropriate timelines for assessment. PMID:24561495
Alper, Philip R.
Given the chorus of approval for primary care emanating from every party to the health reform debate, one might suppose that the future for primary physicians is bright. Yet this is far from certain. And when one looks to history and recognizes that primary care medicine has failed virtually every conceivable market test in recent years, its…
Litchfield, Ian; Bentham, Louise; Hill, Ann; McManus, Richard J; Lilford, Richard; Greenfield, Sheila
Background The testing and result communication process in primary care is complex. Its successful completion relies on the coordinated efforts of a range of staff in primary care and external settings working together with patients. Despite the importance of diagnostic testing in provision of care, this complexity renders the process vulnerable in the face of increasing demand, stretched resources and a lack of supporting guidance. Methods We conducted a series of focus groups with patients and staff across four primary care practices using process-improvement strategies to identify and understand areas where either unnecessary delay is introduced, or the process may fail entirely. We then worked with both patients and staff to arrive at practical strategies to improve the current system. Results A total of six areas across the process were identified where improvements could be introduced. These were: (1) delay in phlebotomy, (2) lack of a fail-safe to ensure blood tests are returned to practices and patients, (3) difficulties in accessing results by telephone, (4) role of non-clinical staff in communicating results, (5) routine communication of normal results and (6) lack of a protocol for result communication. Conclusions A number of potential failures in testing and communicating results to patients were identified, and some specific ideas for improving existing systems emerged. These included same-day phlebotomy sessions, use of modern technology methods to proactively communicate routine results and targeted training for receptionists handling sensitive data. There remains an urgent need for further work to test these and other potential solutions. PMID:26251507
Jones, R; Murphy, E; Crosland, A
Research activity in primary care is increasing rapidly, and raises a range of specific ethical issues. Many of these relate to the involvement of individuals in the community who are not seeking medical care and to the impact of research participation on relationships between general practitioners and their patients. The ethical issues pertinent to a range of quantitative and qualitative research methodologies in primary care are identified and considered. PMID:8554844
Methods for evaluating the impact of vertical programs on health systems: protocol for a study on the impact of the global polio eradication initiative on strengthening routine immunization and primary health care
Background The impact of vertical programs on health systems is a much-debated topic, and more evidence on this complex relationship is needed. This article describes a research protocol developed to assess the relationship between the Global Polio Eradication Initiative, routine immunization, and primary health care in multiple settings. Methods/Design This protocol was designed as a combination of quantitative and qualitative research methods, making use of comparative ethnographies. The study evaluates the impact of the Global Polio Eradication Initiative on routine immunization and primary health care by: (a) combining quantitative and qualitative work into one coherent study design; (b) using purposively selected qualitative case studies to systematically evaluate the impact of key contextual variables; and (c) making extensive use of the method of participant observation to create comparative ethnographies of the impact of a single vertical program administered in varied contexts. Discussion The study design has four major benefits: (1) the careful selection of a range of qualitative case studies allowed for systematic comparison; (2) the use of participant observation yielded important insights on how policy is put into practice; (3) results from our quantitative analysis could be explained by results from qualitative work; and (4) this research protocol can inform the creation of actionable recommendations. Here, recommendations for how to overcome potential challenges in carrying out such research are presented. This study illustrates the utility of mixed-methods research designs in which qualitative data are not just used to embellish quantitative results, but are an integral component of the analysis. PMID:22938708
Spanish doctors are still leaving the country to look for quality work. Ireland is not a country with many Spanish professionals but it is interesting to know its particular Health care system. Ireland is one of the countries with a national health care system, although it has a mixture of private health care insurance schemes. People have a right to health care if they have been living in Ireland at least for a year. Access to the primary care health system depends on age and income: free of charge for Category 1 and co-payments for the rest. This division generates great inequalities among the population. Primary Care doctors are self-employed, and they work independently. However, since 2001 they have tended to work in multidisciplinary teams in order to strengthen the Primary Care practice. Salary is gained from a combination of public and private incomes which are not differentiated. The role of the General Practitioner consists in the treatment of acute and chronic diseases, minor surgery, child care, etc. There is no coordination between Primary and Secondary care. Access to specialised medicine is regulated by the price of consultation. Primary Care doctors are not gatekeepers. To be able to work here, doctors must have three years of training after medical school. After that, Continuing Medical Education is compulsory, and the college of general practitioners monitors it annually. The Irish health care system does not fit into the European model. Lack of a clear separation between public and private health care generates great inequalities. The non-existence of coordination between primary and specialised care leads to inefficiencies, which Ireland cannot allow itself after a decade of economic crisis.
Davies, Joanna M; Gao, Wei; Sleeman, Katherine E; Lindsey, Katie; Murtagh, Fliss E; Teno, Joan M; Deliens, Luc; Wee, Bee; Higginson, Irene J; Verne, Julia
Palliative and end of life care is essential to healthcare systems worldwide, yet a minute proportion of research funding is spent on palliative and end of life care research. Routinely collected health and social care data provide an efficient and useful opportunity for evaluating and improving care for patients and families. There are excellent examples of routine data research in palliative and end of life care, but routine data resources are widely underutilised. We held four workshops on using routinely collected health and social care data in palliative and end of life care. Researchers presented studies from the UK, USA and Europe. The aim was to highlight valuable examples of work with routine data including work with death registries, hospital activity records, primary care data and specialist palliative care registers. This article disseminates that work, describes the benefits of routine data research and identifies major challenges for the future use of routine data, including; access to data, improving data linkage, and the need for more palliative and end of life care specific data.
Davies, Joanna M; Gao, Wei; Sleeman, Katherine E; Lindsey, Katie; Murtagh, Fliss E; Teno, Joan M; Deliens, Luc; Wee, Bee; Higginson, Irene J; Verne, Julia
Palliative and end of life care is essential to healthcare systems worldwide, yet a minute proportion of research funding is spent on palliative and end of life care research. Routinely collected health and social care data provide an efficient and useful opportunity for evaluating and improving care for patients and families. There are excellent examples of routine data research in palliative and end of life care, but routine data resources are widely underutilised. We held four workshops on using routinely collected health and social care data in palliative and end of life care. Researchers presented studies from the UK, USA and Europe. The aim was to highlight valuable examples of work with routine data including work with death registries, hospital activity records, primary care data and specialist palliative care registers. This article disseminates that work, describes the benefits of routine data research and identifies major challenges for the future use of routine data, including; access to data, improving data linkage, and the need for more palliative and end of life care specific data. PMID:26928173
The poor planning of health care professionals in Spain has led to an exodus of doctors leaving the country. France is one of the chosen countries for Spanish doctors to develop their professional career. The French health care system belongs to the Bismarck model. In this model, health care system is financed jointly by workers and employers through payroll deduction. The right to health care is linked to the job, and provision of services is done by sickness-funds controlled by the Government. Primary care in France is quite different from Spanish primary care. General practitioners are independent workers who have the right to set up a practice anywhere in France. This lack of regulation has generated a great problem of "medical desertification" with problems of health care access and inequalities in health. French doctors do not want to work in rural areas or outside cities because "they are not value for money". Medical salary is linked to professional activity. The role of doctors is to give punctual care. Team work team does not exist, and coordination between primary and secondary care is lacking. Access to diagnostic tests, hospitals and specialists is unlimited. Duplicity of services, adverse events and inefficiencies are the norm. Patients can freely choose their doctor, and they have a co-payment for visits and hospital care settings. Two years training is required to become a general practitioner. After that, continuing medical education is compulsory, but it is not regulated. Although the French medical Health System was named by the WHO in 2000 as the best health care system in the world, is it not that good. While primary care in Spain has room for improvement, there is a long way for France to be like Spain.
Global prevalence of antibiotic resistance in paediatric urinary tract infections caused by Escherichia coli and association with routine use of antibiotics in primary care: systematic review and meta-analysis
Hay, Alastair D; Lane, Isabel F; Thornton, Hannah V; Wootton, Mandy; Costelloe, Céire
previous prescriptions for antibiotics in primary care were more likely to be resistant to antibiotics, and this increased risk could persist for up to six months (odds ratio 13.23, 95% confidence interval 7.84 to 22.31). Conclusions Prevalence of resistance to commonly prescribed antibiotics in primary care in children with urinary tract infections caused by E coli is high, particularly in countries outside the OECD, where one possible explanation is the availability of antibiotics over the counter. This could render some antibiotics ineffective as first line treatments for urinary tract infection. Routine use of antibiotics in primary care contributes to antimicrobial resistance in children, which can persist for up to six months after treatment. PMID:26980184
Beardshaw, V; Gordon, P; Plamping, D
Most commentators on the Tomlinson report have agreed with its emphasis on improving primary and community care. The three elements of such a strategy are a remedial programme to bring primary care up to national standards, a programme to provide such services to people with non-standard needs such as mobile Londoners, ethnic minorities, and homeless people, and the development of an expanded model of primary care. No one model will be appropriate across all of London. The process should start with an audit of existing resources and services within each community, together with an analysis of needs. From this would develop a local programme with specific plans for investment in premises, staffing, training, and management. New contractual mechanisms may be needed to attract practitioners, improve their premises, secure out of hours services, and provide medical cover for community beds. There should also be incentives for closer working between primary and secondary services. No developments on the scale needed for London have been carried out in primary care within the lifetime of the NHS--but their success will be critical to the calibre of health services for Londoners into the next century.
Sweden was one of the first European Union countries that saw the opportunity in the free movement of professionals. First offers for jobs were managed in 2000. Since then, a large number of professionals have taken the opportunity of a decent job and have moved from Spain to Sweden. The Swedish health care model belongs to the group of national health systems. The right to health care is linked to legal citizenship. Health is financed through regional taxes, but there is a compulsory co-payment regardless of the financial situation of the patient. The provision of health care is decentralised at a regional level, and there is a mixture of private and public medical centres. Primary care is similar to that in Spain. Health professionals work as a team with a division of tasks. Like in Spain, waiting lists and coordination between primary and specialised care are a great problem. Patients may register with any public or private primary care centre and hospital provider within their region. Access to diagnostic tests and specialists are restricted to those selected by specialists. Doctors are salaried and their job and salary depend on their experience, professional abilities and regional needs. Medicine is curative. General practitioners are the gateway to the system, but they do not act as gatekeeper. Hospitals offer a number of training post, and the access is through an interview. Continuing medical education is encouraged and financed by the health centre in order to increase its revenues.
Benefits of Aldosterone Receptor Antagonism in Chronic Kidney Disease (BARACK D) trial–a multi-centre, prospective, randomised, open, blinded end-point, 36-month study of 2,616 patients within primary care with stage 3b chronic kidney disease to compare the efficacy of spironolactone 25 mg once daily in addition to routine care on mortality and cardiovascular outcomes versus routine care alone: study protocol for a randomized controlled trial
Background Chronic kidney disease (CKD) is common and increasing in prevalence. Cardiovascular disease (CVD) is a major cause of morbidity and death in CKD, though of a different phenotype to the general CVD population. Few therapies have proved effective in modifying the increased CVD risk or rate of renal decline in CKD. There are accumulating data that aldosterone receptor antagonists (ARA) may offer cardio-protection and delay renal impairment in patients with the CV phenotype in CKD. The use of ARA in CKD has therefore been increasingly advocated. However, no large study of ARA with renal or CVD outcomes is underway. Methods The study is a prospective randomised open blinded endpoint (PROBE) trial set in primary care where patients will mainly be identified by their GPs or from existing CKD lists. They will be invited if they have been formally diagnosed with CKD stage 3b or there is evidence of stage 3b CKD from blood results (eGFR 30–44 mL/min/1.73 m2) and fulfil the other inclusion/exclusion criteria. Patients will be randomised to either spironolactone 25 mg once daily in addition to routine care or routine care alone and followed-up for 36 months. Discussion BARACK D is a PROBE trial to determine the effect of ARA on mortality and cardiovascular outcomes (onset or progression of CVD) in patients with stage 3b CKD. Trial registration EudraCT: 2012-002672-13 ISRTN: ISRCTN44522369 PMID:24886488
Belgium is an attractive country to work in, not just for doctors but for all Spanish workers, due to it having the headquarters of European Union. The health job allure is double; on the one hand, the opportunity to find a decent job, and on the other, because it is possible to develop their professional abilities with patients of the same nationality in a health system with a different way of working. The Belgium health care system is based on security social models. Health care is financed by the government, social security contributions, and voluntary private health insurance. Primary care in Belgium is very different to that in Spain. Citizens may freely choose their doctor (general practitioner or specialist) increasing the lack of coordination between primary and specialized care. This leads to serious patient safety problems and loss of efficiency within the system. Belgium is a European country with room to improve preventive coverage. General practitioners are self-employed professionals with free choice of setting, and their salary is linked to their professional activity. Ambulatory care is subjected to co-payment, and this fact leads to great inequities on access to care. The statistics say that there is universal coverage but, in 2010, 14% of the population did not seek medical contact due to economic problems. It takes 3 years to become a General Practitioner and continuing medical education is compulsory to be revalidated. In general, Belgian and Spaniards living and working in Belgium are happy with the functioning of the health care system. However, as doctors, we should be aware that it is a health care system in which access is constrained for some people, and preventive coverage could be improved.
Rollow, William; Cucchiara, Peter
The patient-centered medical home (PCMH) model provides a compelling vision for primary care transformation, but studies of its impact have used insufficiently patient-centered metrics with inconsistent results. We propose a framework for defining patient-centered value and a new model for value-based primary care transformation: the primary care value model (PCVM). We advocate for use of patient-centered value when measuring the impact of primary care transformation, recognition, and performance-based payment; for financial support and research and development to better define primary care value-creating activities and their implementation; and for use of the model to support primary care organizations in transformation.
Showstack, Jonathan; Lurie, Nicole; Larson, Eric B; Rothman, Arlyss Anderson; Hassmiller, Susan
Three decades ago, a renaissance helped create the foundations of primary care as we know it today. In recent years, however, new challenges have confronted primary care. We believe that the current challenges can be overcome and may, in fact, present an opportunity for a new renaissance of primary care to address the needs of our population. In this paper, we suggest seven core principles and a set of actions that will support a renaissance in, and a positive future for, primary care. The seven principles are 1) Health care must be organized to serve the needs of patients; 2) the goal of primary care systems should be the delivery of the highest-quality care as documented by measurable outcomes; 3) information and information systems are the backbone of the primary care process; 4) current health care systems must be reconstructed; 5) the health care financing system must support excellent primary care practice; 6) primary care education must be revitalized, with an emphasis on new delivery models and training in sites that deliver excellent primary care; and 7) the value of primary care practice must be continually improved, documented, and communicated. At the start of the 21st century, a vital, patient-centered primary care system has much to offer a rapidly changing population with increasingly diverse needs and expectations. If we keep the needs of persons and patients clearly in sight and design systems to meet those needs, primary care will thrive and our patients will be well served.
Coates, Allan L; Graham, Brian L; McFadden, Robin G; McParland, Colm; Moosa, Dilshad; Provencher, Steeve; Road, Jeremy
Canadian Thoracic Society (CTS) clinical guidelines for asthma and chronic obstructive pulmonary disease (COPD) specify that spirometry should be used to diagnose these diseases. Given the burden of asthma and COPD, most people with these diseases will be diagnosed in the primary care setting. The present CTS position statement was developed to provide guidance on key factors affecting the quality of spirometry testing in the primary care setting. The present statement may also be used to inform and guide the accreditation process for spirometry in each province. Although many of the principles discussed are equally applicable to pulmonary function laboratories and interpretation of tests by respirologists, they are held to a higher standard and are outside the scope of the present statement. PMID:23457669
Wright, Robert; Saul, Robert A
Epigenetics, the study of functionally relevant chemical modifications to DNA that do not involve a change in the DNA nucleotide sequence, is at the interface between research and clinical medicine. Research on epigenetic marks, which regulate gene expression independently of the underlying genetic code, has dramatically changed our understanding of the interplay between genes and the environment. This interplay alters human biology and developmental trajectories, and can lead to programmed human disease years after the environmental exposure. In addition, epigenetic marks are potentially heritable. In this article, we discuss the underlying concepts of epigenetics and address its current and potential applicability for primary care providers.
Venn, Martha L.; Wolery, Mark
Four paraprofessional staff members in a mainstreamed day care program were trained to engage in positive interactive behaviors during diaper changing. Results indicated that staff increased frequency of game playing and other interactive behaviors during diapering, but increases were not generalized to feeding routines. (Author/JDD)
Sege, Robert; Kaplan-Sanof, Margot; Morton, Samantha J.; Velasco-Hodgson, M. Carolina; Preer, Genevieve; Morakinyo, Grace; DeVos, Ed; Krathen, Julie
Project DULCE (Developmental understanding and legal Collaboration for everyone) integrated the Strengthening families approach to building family protective factors into routine health care visits for infants in a primary health care setting. The core collaborators--Boston medical Center pediatric primary care, the medical-legal partnership |…
de Lusignan, Simon
Primary care informatics is an emerging academic discipline that remains undefined. The unique nature of primary care necessitates the development of its own informatics discipline. A definition of primary care informatics is proposed, which encompasses the distinctive nature of primary care. The core concepts and theory that should underpin it are described. Primary care informatics is defined as a science and as a subset of health informatics. The proposed definition is intended to focus the development of a generalizable core theory for this informatics subspecialty. PMID:12668690
Steciwko, Andrzej; Lubieniecka, Małgorzata; Muszyńska, Agnieszka
Discovered in the forties of the twentieth century antimicrobial agents have changed the world. Currently, due to their overuse, we are threatened by the increasing resistance of bacteria to antibiotics, and soon we may face a threat of inability to fight these pathogens. For that reason, the world, European and national organizations introduce antibiotics protection programs. In Poland since 2004, the National Program of Protection of Antibiotics is being held. The concept of rational antibiotic therapy is associated not only with the appropriate choice of therapy or antimicrobial dosage but also with a reduction in costs associated with a refund of medicines. Antibiotics are prescribed mostly by primary care physicians (GP), and about one fifth of visits to family doctor's office ends with prescribing antimicrobial drug. These trends are probably related to both the difficulty in applying the differential diagnosis of viral and bacterial infection in a primary care doctor's office, as well as patient's conviction about the effectiveness of antibiotic therapy in viral infections. However, although patients often want to influence the therapeutic decisions and ask their doctor for prescribing antimicrobial drug, the right conversation with a doctor alone is the critical component in satisfaction with medical care. Many countries have established standards to clarify the indications for use of antibiotics and thereby reduce their consumption. The next step is to monitor the prescribing and use of these drugs and to assess the rise of drug resistance in the area. In Poland, the recommendations regarding outpatient respiratory tract infections treatment were published and usage of antimicrobial agents monitoring has begun. However, lack of publications covering a broad analysis of antibiotic therapy and drug resistance on Polish territory is still a problem. Modem medicine has yet another tool in the fight against bacteria--they are bacteriophages. Phage therapy is
Rollow, William; Cucchiara, Peter
The patient-centered medical home (PCMH) model provides a compelling vision for primary care transformation, but studies of its impact have used insufficiently patient-centered metrics with inconsistent results. We propose a framework for defining patient-centered value and a new model for value-based primary care transformation: the primary care value model (PCVM). We advocate for use of patient-centered value when measuring the impact of primary care transformation, recognition, and performance-based payment; for financial support and research and development to better define primary care value-creating activities and their implementation; and for use of the model to support primary care organizations in transformation. PMID:26951592
Green, Carla A.; Johnson, Kim M.; Yarborough, Bobbi Jo H.
Purpose To explore/identify patient perspectives regarding seeking, delaying, and avoiding health care services, particularly barriers and facilitators. Design Face-to-face interviews with health plan survey respondents. Setting An integrated health plan providing comprehensive care to 480,000 people in Oregon and Washington. Participants Willing respondents randomly selected to maximize heterogeneity within the following strata: gender, health care utilization, and self-reported alcohol consumption (indicator of health practices). Participants were 75 men and 75 women (150 total), 21–64 years old, with ≥12 months of health plan membership. Method Participants were recruited by letter (52.5% agreed). Data collection stopped when planned interviews were completed; saturation (the point at which additional interviews were not producing novel information) was achieved for key study questions. Semi-structured interviews were recorded, transcribed, and coded. Reviews of codes related to care seeking and feelings/attitudes about providers produced common themes. Results Facilitators of care seeking included welcoming staff, collaborative relationships with providers, and education about the value of preventive care. Barriers included costs, time needed for appointments, and cumbersome processes. Some participants delayed procedures, some avoided care until absolutely necessary, others framed care as routinely necessary. Conclusion Increasing comfort, improving appointment and visit-related processes, having positive patient-physician relationships, and enhancing communication and clinician-provided education may facilitate appropriate use of preventive services. Further research is needed with larger, representative, samples to evaluate findings. PMID:23971522
Brown, Judith Belle; French, Reta; McCulloch, Amy; Clendinning, Eric
Abstract Objective To explore the knowledge and perceptions of fourth-year medical students regarding the new models of primary health care (PHC) and to ascertain whether that knowledge influenced their decisions to pursue careers in family medicine. Design Qualitative study using semistructured interviews. Setting The Schulich School of Medicine and Dentistry at The University of Western Ontario in London. Participants Fourth-year medical students graduating in 2009 who indicated family medicine as a possible career choice on their Canadian Residency Matching Service applications. Methods Eleven semistructured interviews were conducted between January and April of 2009. Data were analyzed using an iterative and interpretive approach. The analysis strategy of immersion and crystallization assisted in synthesizing the data to provide a comprehensive view of key themes and overarching concepts. Main findings Four key themes were identified: the level of students’ knowledge regarding PHC models varied; the knowledge was generally obtained from practical experiences rather than classroom learning; students could identify both advantages and disadvantages of working within the new PHC models; and although students regarded the new PHC models positively, these models did not influence their decisions to pursue careers in family medicine. Conclusion Knowledge of the new PHC models varies among fourth-year students, indicating a need for improved education strategies in the years before clinical training. Being able to identify advantages and disadvantages of the PHC models was not enough to influence participants’ choice of specialty. Educators and health care policy makers need to determine the best methods to promote and facilitate knowledge transfer about these PHC models. PMID:22518904
Talmi, Ayelet; Stafford, Brian; Buchholz, Melissa
After birth, newborns and their caregivers are seen routinely and frequently in pediatric primary care settings. The close succession of visits in the first few months of life puts pediatric primary care professionals in a unique position to enhance infant mental health by developing strong relationships with caregivers, supporting babies and…
Routman, Justin S.; Willig, James H.; Westfall, Andrew O.; Abroms, Sarah R.; Varshney, Mohit; Adusumilli, Sunil; Allison, Jeroan J.; Savage, Karen G.; Saag, Michael S.; Mugavero, Michael J.
Summary The generalizability of clinical trial findings (efficacy) to routine care (effectiveness) may be limited. The present study found similar first year virologic and CD4 outcomes among antiretroviral-naïve patients treated through routine care vs. those participating in clinical trials. Background The generalizability of clinical trial findings (efficacy) to routine care (effectiveness) may be limited due to study eligibility criteria and volunteer bias. While well chronicled in many conditions, the efficacy vs. effectiveness of antiretroviral therapy (ART) remains understudied. Methods A retrospective study of the UAB 1917 Clinic Cohort evaluated naïve patients starting ART between 1/1/00–12/31/06. Patients received ART through clinical trials or routine care. Multivariable logistic and linear regression models were fit to evaluate factors associated with virologic failure (VF=VL>50 copies/mL) and change from baseline CD4 count 6 and 12 months after ART initiation. Sensitivity analyses evaluated the impact of missing data on outcomes. Results Among 570 patients starting ART during the study period, 121 (21%) enrolled in clinical trials vs. 449 (79%) receiving ART via routine care. ART receipt through routine care was not associated with VF at either 6 (OR=1.00;95%CI=0.54–1.86) or 12 (OR=1.56;95%CI=0.80–3.05) months in primary analyses. No significant differences in CD4 count responses at 6 and 12 months were observed. Conclusions Though marked differences in efficacy vs. effectiveness have been observed in the therapeutic outcomes of other conditions, our analyses found no evidence of such divergence among our patients initiating antiretroviral therapy for HIV. PMID:20067423
Ellner, Andrew L; Phillips, Russell S
The United States has the most expensive, technologically advanced, and sub-specialized healthcare system in the world, yet it has worse population health status than any other high-income country. Rising healthcare costs, high rates of waste, the continued trend towards chronic non-communicable disease, and the growth of new market entrants that compete with primary care services have set the stage for fundamental change in all of healthcare, driven by a revolution in primary care. We believe that the coming primary care revolution ought to be guided by the following design principles: 1) Payment must adequately support primary care and reward value, including non-visit-based care. 2) Relationships will serve as the bedrock of value in primary care, and will increasingly be fostered by teams, improved clinical operations, and technology, with patients and non-physicians assuming an ever-increasing role in most aspects of healthcare. 3) Generalist physicians will increasingly focus on high-acuity and high-complexity presentations, and primary care teams will increasingly manage conditions that specialists managed in the past. 4) Primary care will refocus on whole-person care, and address health behaviors as well as vision, hearing, dental, and social services. Design based on these principles should lead to higher-value healthcare, but will require new approaches to workforce training.
Ariza, Adolfo J; Ruch-Ross, Holly; Sawyer, Alexis; Batey, Sue; Maloney, Michelle; Wall, Tim; Hines, Valerie; Robles, Kattia; Sontag, Debbie; Haverkamp, Karen Susan; Lopez, Susan; Binns, Helen J
We evaluated pediatric obesity clinics for internal referrals developed at 5 primary care offices. Clinics developed site-specific strategies: 1 group approach and 4 clinics providing individualized care only. Clinicians reported patient/family motivation as an important referral consideration and compliance as the greatest challenge and perceive clinics to have provided some help.
Hart, J T
The extremely complex and rapidly but unevenly developing system of primary care in Spain is described. The health centre movement in Spain merits close attention, and could be a useful model for our own service. PMID:2117951
Family doctor - how to choose one; Primary care provider - how to choose one; Doctor - how to choose a family doctor ... A PCP is your main health care provider in non-emergency ... and teach healthy lifestyle choices Identify and treat common ...
Alpert, J J
Primary care is about the intimate contact that takes place when a patient comes to the physician because that individual is concerned that he or she, son or daughter, parent or grandparent is sick, or is well and wants to stay well. Our history has been that we have paid attention to important problems but we have missed so far on primary care as a megatrend. As noted, one of our most important societal megatrends is proverty and how poverty places children at risk. Poverty and primary care are linked. The reality that all of our citizens do not have access to primary care is not just our failure but it is society's as well. We pediatricians face many problems. In developing solutions, historically our profession has never lost sight of the fact that we are a helping and caring discipline. We are an advocate for the poor, advocates for children, advocates for community, and that is a large job. But the challenge is real, and we do not have much time. Now is not the time to be timid. We need to achieve consensus, accepting and acting on the megatrend of securing the future for primary care.
Antonio, Gisele Damian; Tesser, Charles Dalcanale; Moretti-Pires, Rodrigo Otavio
OBJECTIVE To characterize the integration of phytotherapy in primary health care in Brazil. METHODS Journal articles and theses and dissertations were searched for in the following databases: SciELO, Lilacs, PubMed, Scopus, Web of Science and Theses Portal Capes, between January 1988 and March 2013. We analyzed 53 original studies on actions, programs, acceptance and use of phytotherapy and medicinal plants in the Brazilian Unified Health System. Bibliometric data, characteristics of the actions/programs, places and subjects involved and type and focus of the selected studies were analyzed. RESULTS Between 2003 and 2013, there was an increase in publications in different areas of knowledge, compared with the 1990-2002 period. The objectives and actions of programs involving the integration of phytotherapy into primary health care varied: including other treatment options, reduce costs, reviving traditional knowledge, preserving biodiversity, promoting social development and stimulating inter-sectorial actions. CONCLUSIONS Over the past 25 years, there was a small increase in scientific production on actions/programs developed in primary care. Including phytotherapy in primary care services encourages interaction between health care users and professionals. It also contributes to the socialization of scientific research and the development of a critical vision about the use of phytotherapy and plant medicine, not only on the part of professionals but also of the population. PMID:25119949
Combs, Heidi; Markman, Jesse
Anxiety disorders are the most common psychiatric condition presenting to primary care practitioners. Yet they can be easily overlooked or misdiagnosed. Patients that struggle with anxiety disorders are more likely to seek treatment from primary care providers than mental health specialists. Given the costs in terms of debilitation and associated financial burden, and increased risk of suicide, the identification and successful treatment of anxiety is imperative. By means of clinical acumen and the use of screening tools, the provider can develop expertise in recognition and effective treatment of anxiety disorders.
Xavier Gomes, Ludmila Mourão; de Andrade Barbosa, Thiago Luis; Souza Vieira, Elen Débora; Caldeira, Antônio Prates; de Carvalho Torres, Heloísa; Viana, Marcos Borato
Objective To analyze the perception of primary care physicians and nurses about access to services and routine health care provided to sickle cell disease patients. Methods This descriptive exploratory study took a qualitative approach by surveying thirteen primary care health professionals who participated in a focus group to discuss access to services and assistance provided to sickle cell disease patients. The data were submitted to thematic content analysis. Results Access to primary care services and routine care for sickle cell disease patients were the categories that emerged from the analysis. Interaction between people with sickle cell disease and primary care health clinics was found to be minimal and limited mainly to scheduling appointments. Patients sought care from the primary care health clinics only in some situations, such as for pain episodes and vaccinations. The professionals noted that patients do not recognize primary care as the gateway to the system, and reported that they feel unprepared to assist sickle cell disease patients. Conclusion In the perception of these professionals, there are restrictions to accessing primary care health clinics and the primary care assistance for sickle cell disease patients is affected. PMID:26190428
Isaac, Kathleen S; Hay, Jennifer L; Lubetkin, Erica I
Addressing cultural competency in health care involves recognizing the diverse characteristics of the patient population and understanding how they impact patient care. Spirituality is an aspect of cultural identity that has become increasingly recognized for its potential to impact health behaviors and healthcare decision-making. We consider the complex relationship between spirituality and health, exploring the role of spirituality in primary care, and consider the inclusion of spirituality in existing models of health promotion. We discuss the feasibility of incorporating spirituality into clinical practice, offering suggestions for physicians.
Collins, Kerry A.; Wolfe, Vicky V.; Fisman, Sandra; DePace, JoAnne; Steele, Margaret
OBJECTIVE To investigate family physicians’ practice patterns for managing depression and mental health concerns among adolescent and adult patients. DESIGN Cross-sectional survey. SETTING London, Ont, a mid-sized Canadian city. PARTICIPANTS One hundred sixty-three family physicians identified through the London and District Academy of Medicine. MAIN OUTCOME MEASURES Practice patterns for managing depression, including screening, pharmacotherapy, psychotherapy, shared care, and training needs. RESULTS Response rate was 63%. Family physicians reported spending a substantial portion of their time during patient visits (26% to 50%) addressing mental health issues, with depression being the most common issue (51% to 75% of patients with mental health issues). About 40% of respondents did routine mental health screening, and 60% screened patients with risk factors for depression. Shared care with mental health professionals was common (care was shared for 26% to 50% of patients). Physicians and patients were moderately satisfied with shared care, but were frustrated by long waiting lists and communication barriers. Most physicians provided psychotherapy to patients in the form of general advice. Differences in practice patterns were observed; physicians treated more adults than adolescents with depression, and they reported greater comfort in treating adults. Although 33% of physicians described using cognitive behavioural therapy (CBT), they reported having little training in CBT. Moderate interest was expressed in CBT training, with a preference for a workshop format. CONCLUSION Although 40% of family physicians routinely screen patients for mental health issues, depression is often not detected. Satisfaction with shared care can be increased through better communication with mental health professionals. Physicians’ management of adolescent patients can be improved by further medical training, consultation, and collaboration with mental health professionals
Neenan, M. Elaine; And Others
A study describes the characteristics of the current primary dental care workforce (dentists, hygienists, assistants), its distribution, and its delivery system in private and public sectors. Graduate dental school enrollments, trends in patient visits, employment patterns, state dental activities, and workforce issues related to health care…
Impetigo is a superficial, but contagious, bacterial infection of the skin that predominantly affects children and is common in primary care. In UK general practice, around half of the people with impetigo are treated with topical fusidic acid. However, bacterial resistance to this antibacterial drug is increasing. Here we discuss how patients with impetigo should be treated.
Goldfarb, C. E.; Roberts, W.
Monitoring child development is an essential part of primary health care. Successful surveillance depends on physicians' thorough knowledge of normal progress along the four developmental streams: motor, language, cognitive, and social and emotional. Being alert to "red flags" that suggest problems is important. Effective interventions can minimize developmental problems. PMID:8792021
Sison, Nathan; Yolken, Annajane; Poceta, Joanna; Mena, Leandro; Chan, Philip A; Barnes, Arti; Smith, Erin; Nunn, Amy
The Mississippi Delta region is one of the communities most heavily impacted by HIV/AIDS in the United States. To understand local provider attitudes and practices regarding HIV testing and care, we conducted 25 in-depth qualitative interviews with local primary care providers and infectious disease specialists. Interviews explored attitudes and practices regarding HIV testing and linkage to care. Most providers did not routinely offer HIV testing, noting financial barriers, financial disincentives to offer routine screening, misperceptions about local informed consent laws, perceived stigma among patients, and belief that HIV testing was the responsibility of the health department. Barriers to enhancing treatment and care included stigma, long distances, lack of transportation, and paucity of local infectious disease specialists. Opportunities for enhancing HIV testing and care included provider education programs regarding billing, local HIV testing guidelines, and informed consent, as well as telemedicine services for underserved counties. Although most health care providers in our study did not currently offer routine HIV testing, all were willing to provide more testing and care services if they were able to bill for routine testing. Increasing financial reimbursement and access to care, including through the Affordable Care Act, may provide an opportunity to enhance HIV/AIDS services in the Mississippi Delta.
Brown, Jonathan D
Systems of care should be defined in a manner that includes primary care. The current definition of systems of care shares several attributes with the definition of primary care: both are defined as community-based services that are accessible, accountable, comprehensive, coordinated, culturally competent, and family focused. However, systems of care is defined as serving only children and youth with serious emotional disturbance and their families and does not fully embrace the concept of primary prevention. Although similarities in the definitions of primary care and systems of care may provide a theoretical foundation for including primary care within the systems of care framework, a definition of systems of care that incorporates the idea of prevention and takes into account the broad population served in primary care would provide communities with a definition that can be used to further the work of integrating primary care into systems of care.
Shallcross, Laura J; Petersen, Irene; Rosenthal, Joe; Johnson, Anne M; Freemantle, Nick; Hayward, Andrew C
Using a primary care database, we identified a major increase in impetigo in the United Kingdom during 1995-2010. Despite a doubled rate of primary care consultations, this increase was not identified by routine surveillance. Primary care databases are a valuable and underused source of surveillance data on infectious diseases.
The Australian Government is wise to examine other health care systems as it strives to improve the quality of care and address rising costs to both governments and individuals. Focus is currently on the United Kingdom, whose National Health Service (NHS) stands out as one that delivers good care at a reasonable price to all who need it. The Australian and UK systems have many similarities: universal access, tax payer support, no or low cost at point of delivery, and good population health outcomes. They also face similar pressures on services from aging, increasingly unwell yet expectant populations.However, there are also differences, largely in the way that health care is funded, organised and delivered. The NHS is a huge system for 60 million people in four home countries with diverging policies. Within England, the system is managed through 10 strategic health authorities, each responsible for about 5 million people and having the right to interpret national policy. Population based health care, including tertiary care, is funded locally via primary care trusts.
Fridh, Isabell; Forsberg, Anna; Bergbom, Ingegerd
The purpose of this study was to describe family care routines and to explore environmental factors when patients die in Swedish intensive care units (ICUs). The main research questions were: what are the physical environmental circumstances and facilities when caring for patients in end-of-life and are there any routines or guidelines when caring for dying patients and their families? A questionnaire was sent to 79 eligible Swedish ICUs in December 2003, addressed to the unit managers. The response rate was 94% (n = 74 units). The findings show that, despite recommendations highlighting the importance of privacy for dying ICU patients and their families, only 11% of the respondents stated that patients never died in shared rooms in their ICU. If a patient dies in a shared room, nurses strive to ensure a dignified goodbye by moving the body to an empty room or to one specially designated for this purpose. The majority (76%) of the units had waiting rooms within the ICU. The study also revealed that there is a need for improvements in the follow-up routines for bereaved families. Many units reported (51%) that they often or almost always offer a follow-up visit, although in most cases the bereaved family had to initiate the follow-up by contacting the ICU. Guidelines in the area of end-of-life care were used by 25% of the ICUs. Further research is necessary to acquire a deeper knowledge of the circumstances under which patients die in ICUs and what impact the ICU environment has on bereaved families.
Tang, Chiung-Ya; Lin, Yi-Ling; Masri, Maysoun Dimachkie
Background The Accountable Care Organization (ACO) is one of the new models of health care delivery in the U.S. To date, little is known about the characteristics of health care organizations that have joined ACOs. We report on the findings of a survey of primary care clinics, the objective of which was to investigate the opinions of clinic management about participation in ACOs, and the characteristics of clinic organizational structure that may contribute to joining ACOs or be willing to do so. Methods A 27-item survey questionnaire was developed and distributed by mail in 3 annual waves to all Rural Health Clinics (RHCs) in 9 states. Two dependent variables - participation in ACOs and willingness to join ACOs - were created and analyzed using a generalized estimating equation (GEE) approach. Results 257 RHCs responded to the survey. A small percentage (5.2%) of the respondent clinics reported that they were participating in ACOs. RHCs in isolated areas were 78% less likely to be in ACOs (odds= 0.22, p= 0.059). Non-profit RHCs indicated a higher willingness to join an ACO than for-profit RHCs (B= 1.271, p= 0.054). There is a positive relationship between RHC size and willingness to join an ACO (B= 0.402, p=0.010). Conclusions At this early stage of ACO development, many RHC personnel are unfamiliar with the ACO model. Rural providers’ limited technological and human resources, and the lack of ACO development in rural areas, may delay or prevent their participation in ACOs. PMID:26900587
Kilbourne, Amy M.; Goodrich, David E.; O’Donnell, Allison N.; Miller, Christopher J.
There is growing realization that persons with bipolar disorder may exclusively be seen in primary (general medical) care settings, notably because of limited access to mental health care and stigma in seeking mental health treatment. At least two clinical practice guidelines for bipolar disorder recommend collaborative chronic care models (CCMs) to help integrate mental health care to better manage this illness. CCMs, which include provider guideline support, self-management support, care management, and measurement-based care, are well-established in primary care settings, and may help primary care practitioners manage bipolar disorder. However, further research is required to adapt CCMs to support complexities in diagnosing persons with bipolar disorder, and integrate decision-making processes regarding medication safety and tolerability in primary care. Additional implementation studies are also needed to adapt CCMs for persons with bipolar disorder in primary care, especially those seen in smaller practices with limited infrastructure and access to mental health care. PMID:23001382
... 45 Public Welfare 1 2010-10-01 2010-10-01 false Primary care. 96.47 Section 96.47 Public Welfare... and Tribal Organizations § 96.47 Primary care. Applications for direct funding of Indian tribes and tribal organizations under the primary care block grant must comply with 42 CFR Part 51c (Grants...
Simonian, Susan J.
This article reviews issues related to behavioral screening in pediatric primary care settings. Structural-organizational issues affecting the use of pediatric primary care screening are discussed. This study also reviewed selected screening instruments that have utility for use in the primary care setting. Clinical and research issues related to…
Bindman, A B
The use of primary and managed care is likely to increase under proposed federal health care reform. I review the definition of primary care and primary care physicians and show that this delivery model can affect access to medical care, the cost of treatment, and the quality of services. Because the use of primary care is often greater in managed care than in fee-for-service, I compare the two insurance systems to further understand the delivery of primary care. Research suggests that primary care can help meet the goal of providing accessible, cost-effective, and high-quality care, but that changes in medical education and marketplace incentives will be needed to encourage students and trained physicians to enter this field. PMID:7941522
Giordani, Jessye Melgarejo do Amaral; Ferla, Alcindo Antônio; Hugo, Fernando Neves
This cross-sectional study aimed to evaluate the association between sociodemographic characteristics, health care indicators, work process characteristics, and the performance of preventive dental procedures by oral health care teams (OHCTs) assessed during the first phase of the PMAQ in Brazil. A census of 10 334 primary OHCTs was conducted. The outcome included topical application of fluoride, application of sealants, detection of oral lesions, and monitoring of suspected or confirmed cases of oral cancer. The multilevel Poisson regression model was used to obtain crude and adjusted prevalence ratios. The performance of preventive dental procedures was 29.46% (3044/10 334; 95% confidence interval, 28.57-30.33), which was considered low. PMID:28252501
Martin, J; Braun, J-P
In areas requiring maximum safety like intensive care units or operating room departments, modern quality management and risk management are essential. Treatment of critically ill patients is associated with high risk and, therefore, demands risk management and quality management. External quality assessment in intensive care medicine has been developed based on a core data set and quality indicators. A peer review procedure has been established. In addition, regional networks of intensive care physicians result in improved local networking. In intensive care medicine, this innovative modular system of quality management and risk management is pursued more consequently than in any other specialty.
Moultrie, Nicolette M.; Heckman, Barbara; Gansky, Stuart A.; Potter, Michael B.; Walsh, Margaret M.
BACKGROUND AND OBJECTIVE: Applying topical fluoride varnish (FV) to young children’s teeth is an effective therapeutic strategy for preventing early childhood caries (ECC). In 2008, the pediatricians at Contra Costa Regional Medical Center and Health Centers became concerned that our low-income pediatric patients had high rates of ECC and very limited access to dental care. We formed an interdisciplinary safety net-academic partnership with the University of California San Francisco to implement routine FV applications, along with oral health education, screening, and referral during well-child exams for children aged 1 to 5 years. METHODS: Over 3 years, the team developed clinical policies, educational materials, billing, and support systems to facilitate implementation in the primary care setting. A pilot study was performed in 2 health centers; improvements to the implementation plan were made. A team of local providers and academic partners performed system-wide didactic and hands-on trainings and spread this intervention to the remaining 6 health centers. Continued improvement strategies and provider feedback were pursued with each measurement cycle. RESULTS: In August 2012, 95% of all children aged 1 to 5 years who were seen for well-child checkups received a FV application and oral health education during their primary care well visit. Repeat measurement in April 2014 showed a sustained rate of 97% application of FV for children in this age group seen for well-child visits. CONCLUSIONS: With institutional commitment and an academic partnership, a safety net institution can integrate routine FV applications and oral health interventions into well-child visits to reduce ECC. PMID:26647374
Fazio, Sara B; Demasi, Monica; Farren, Erin; Frankl, Susan; Gottlieb, Barbara; Hoy, Jessica; Johnson, Amanda; Kasper, Jill; Lee, Patrick; McCarthy, Claire; Miller, Kathe; Morris, Juliana; O'Hare, Kitty; Rosales, Rachael; Simmons, Leigh; Smith, Benjamin; Treadway, Katherine; Goodell, Kristen; Ogur, Barbara
In light of the increasing demand for primary care services and the changing scope of health care, it is important to consider how the principles of primary care are taught in medical school. While the majority of schools have increased students' exposure to primary care, they have not developed a standardized primary care curriculum for undergraduate medical education. In 2013, the authors convened a group of educators from primary care internal medicine, pediatrics, family medicine, and medicine-pediatrics, as well as five medical students to create a blueprint for a primary care curriculum that could be integrated into a longitudinal primary care experience spanning undergraduate medical education and delivered to all students regardless of their eventual career choice.The authors organized this blueprint into three domains: care management, specific areas of content expertise, and understanding the role of primary care in the health care system. Within each domain, they described specific curriculum content, including longitudinality, generalism, central responsibility for managing care, therapeutic alliance/communication, approach to acute and chronic care, wellness and prevention, mental and behavioral health, systems improvement, interprofessional training, and population health, as well as competencies that all medical students should attain by graduation.The proposed curriculum incorporates important core features of doctoring, which are often affirmed by all disciplines but owned by none. The authors argue that primary care educators are natural stewards of this curriculum content and can ensure that it complements and strengthens all aspects of undergraduate medical education.
Brown, Jonathan D.
Systems of care should be defined in a manner that includes primary care. The current definition of systems of care shares several attributes with the definition of primary care: both are defined as community-based services that are accessible, accountable, comprehensive, coordinated, culturally competent, and family focused. However, systems of…
Jensen, K. M.; Taylor, L. C.; Davis, M. M.
Background: Due to significant medical improvements, persons with Down syndrome now live well into adulthood. Consequently, primary care for adults with Down syndrome needs to incorporate routine care with screening for condition-specific comorbidities. This study seeks to evaluate the adherence of primary care physicians to age- and…
Webb, Heather; Street, Jackie; Marshall, Helen
Immunization against pertussis, influenza, and rubella reduces morbidity and mortality in pregnant women and their offspring. Health care professionals (HCPs) caring for women perinatally are uniquely placed to reduce maternal vaccine preventable diseases (VPDs). Despite guidelines recommending immunization during the perinatal period, maternal vaccine uptake remains low. This qualitative study explored the role of obstetricians, general practitioners, and midwives in maternal vaccine uptake. Semi-structured interviews (n = 15) were conducted with perinatal HCPs at a tertiary maternity hospital in South Australia. HCPs were asked to reflect on their knowledge, beliefs, and practice relating to immunization advice and vaccine provision. Interviews were transcribed and coded using thematic analysis. Data collection and analysis was an iterative process, with collection ceasing with theoretical saturation. Participants unanimously supported maternal vaccination as an effective way of reducing risk of disease in this vulnerable population, however only rubella immunity detection and immunization is embedded in routine care. Among these professionals, delegation of responsibility for maternal immunization was unclear and knowledge about maternal immunization was variable. Influenza and pertussis vaccine prevention measures were not included in standard pregnancy record documentation, information provision to patients was “ad hoc” and vaccinations not offered on-site. The key finding was that the incorporation of maternal vaccinations into standard care through a structured process is an important facilitator for immunization uptake. Incorporating vaccine preventable disease management measures into routine obstetric care including incorporation into the Pregnancy Record would facilitate HCPs in implementing recommendations. Rubella prevention provides a useful “template” for other vaccines. PMID:24509790
Wiedermann, Ursula; Garner-Spitzer, Erika; Wagner, Angelika
There are 2 major factors responsible for vaccine failures, the first is vaccine-related such as failures in vaccine attenuation, vaccination regimes or administration. The other is host-related, of which host genetics, immune status, age, health or nutritional status can be associated with primary or secondary vaccine failures. The first describes the inability to respond to primary vaccination, the latter is characterized by a loss of protection after initial effectiveness. Our studies concentrate on the evaluation of immunological characteristics responsible for primary vaccine failures in different (risk) populations for which the underlying mechanisms are currently unknown. Here we summarise current knowledge and findings from our studies. About 2-10% of healthy individuals fail to mount antibody levels to routine vaccines. Comparing the immune responses to different vaccines in non-responder and high-responder vaccinees revealed that hypo-responsiveness is antigen/vaccine-specific at the humoral but not at the cellular level. We found that T-regulatory as well as B-regulatory cells and the production of IL-10 are involved in non/hypo-responsiveness. Non-responsiveness increases with age and in particular vaccination to a novel vaccine in persons > 65 years is associated with a high low/non-responder rate, indicating that vaccine schedules and doses (at least for primary vaccination) should be adapted according to age. In light of the growing number of allergic but also obese people, our current studies concentrate on these risk groups to reveal whether different vaccination approaches are necessary for optimal protection compared to healthy individuals. These studies are in line with the significant paradigm shift taking place in many fields of medical research and care, and will extend the concept of personalised medicine into the field of vaccinology.
'Selective primary health care' and other recent vertical health strategies have been justified on the grounds that the broad primary health care (PHC) approach cannot be afforded by developing countries in the present constrained economic circumstances. This judgement is too sweeping. A simulated case example is presented, starting with baseline health expenditure data that are representative of the situation in many developing countries. It is assumed that real economic growth occurs and that government funding of health care is allowed to grow in parallel. Two annual growth rates are considered: 2 and 5 per cent. Two restrictive conditions are applied: none of the main health services is subjected to absolute cuts; and, additional funds from existing or new sources of finance are not considered. It is shown that, even with slow growth rates, substantial increases in the funding of priority (rural and PHC) services can be achieved if the growth in expenditures of lower-priority services is curtailed. Also, savings from improved health service efficiency can be channelled to priority services. The message is that the PHC approach is viable even with slow economic growth. What is required is the technical capacity to identify and plan resource flows in the health sector, and the political will to effect resource allocations according to PHC priorities. A strategic policy like PHC should not be 'adjusted' out of effective existence because of reversible economic problems. Rather, actions should be taken to reverse the adverse economic environment. International health-related agencies should continue to support countries to develop national health systems based on PHC, and should campaign for reforms in the world economy to create at least the minimum economic conditions necessary for PHC implementation.
Drennan, Vari; Andrews, Sarah; Sidhu, Rajinder; Peacock, Richard
There is increasing demand for nurses to work in primary care. This is driven in part by the need to retain current levels but also by the modernisation plans for primary care services, which require new roles for nurses, new ways of working and more nurses in primary care settings. While campaigns for increased recruitment of hospital nurses and doctors has been largely successful in recent years, primary care has still to see the impact. This article reports on a Department of Health (England) funded project that aimed to identify strategies and exemplars to assist primary care trusts (PCTs) and the workforce development confederations (WDCs) in strategic health authorities in attracting and retaining nurses to primary care at registered nurse level. It reports on the range of initiatives identified, the perceived benefits and challenges. It concludes by proposing a strategic model for planning for the recruitment and retention of primary care nurses.
Realization of health care as primary objective is necessary to strengthen primary health care (PHC). There is a need to build financial viable and sustainable PHC based on rational principles to fulfill the goals of providing quality health services on an affordable and equitable basis and also ensuring fiscal prudence. Health-care leadership, innovations in primary care, family medicine specialists, and effective and accountable health governance are the key steps toward our goal. PMID:28217580
Rotar Pavlič, Danica; Zelko, Erika; Vintges, Marga; Willems, Sara; Hanssens, Lise
Abstract Roma populations’ low health status and limited access to health services, including primary care, has been documented in many European countries, and warrants specific health policies and practices. A variety of experiences shows how primary care can adjust its practices to reduce the barriers to primary care for Roma populations. At local level, establishing collaboration with Roma organisations helps primary care to improve mutual relations and quality of care. Mediation has proved to be an effective tool. Skills training of primary care practitioners may enhance their individual competences. Research and international sharing of experiences are further tools to improve primary care for the Roma people. PMID:27703542
Luctkar-Flude, Marian; Aiken, Alice; McColl, Mary Ann; Tranmer, Joan; Langley, Hugh
Abstract Objective To describe the implementation of key best practice guideline recommendations for posttreatment breast cancer survivorship care by primary care providers (PCPs). Design Descriptive cross-sectional survey. Setting Southeastern Ontario. Participants Eighty-two PCPs: 62 family physicians (FPs) and 20 primary health care nurse practitioners (PHCNPs). Main outcome measures Twenty-one “need-to-know” breast cancer survivorship care guideline recommendations rated by participants as “implemented routinely,” “aware of guideline recommendation but not implemented routinely,” or “not aware of guideline recommendation.” Results Overall, FPs and PHCNPs in our sample reported similar practice patterns in terms of implementation of breast cancer survivorship guideline recommendations. The PCPs reported routinely implementing approximately half (46.4%, 9.7 of 21) of the key guideline recommendations with breast cancer survivors in their practices. Implementation rates were higher for recommendations related to prevention and surveillance aspects of survivorship care, such as mammography and weight management. Knowledge and practice gaps were highest for recommendations related to screening for and management of long-term effects such as fatigue and distress. There were only a few minor differences reported between FPs and PHCNPs. Conclusion There are knowledge and practice gaps related to implementation of the key guideline recommendations for breast cancer survivorship care in the primary care setting that could be targeted for improvement through educational or other interventions. PMID:26889509
Evaniew, Allison L; Evaniew, Nathan
AIM To discusses pharmacological and non-pharmacological therapeutic alternatives for managing knee osteoarthritis in primary care by primary health care nurse practitioners. METHODS A case example is presented, the evidence-based guideline recommendations of the Osteoarthritis Research Society International and the American Academy of Orthopaedic Surgeons are reviewed, and a plan of care is developed. RESULTS Osteoarthritis is the most common form of arthritis seen in primary care, and it is a major public health issue because the aging population and widespread obesity have drastically increased incidence. Osteoarthritis is clinically associated with escalating chronic pain, physical disability, and decreased quality of life. Early diagnosis of mild osteoarthritis in relatively young patients presents an opportunity for primary health care providers to manage pain, increase quality of life, and decrease risk of disability. CONCLUSION Primary health care providers can implement these recommendations in their own practices to provide care to patients with knee osteoarthritis based on current best evidence. PMID:28251070
Eaton, Charles B; McBride, Patrick E; Gans, Kim A; Underbakke, Gail L
Primary care physicians have the potential to decrease morbidity and mortality for many chronic diseases if they provide effective nutrition counseling. Given the time constraints of primary care practice, nutrition counseling needs to be brief, be part of an organized office system and refer appropriate patients to qualified nutrition professionals to be effective. This paper reviews a system of primary care nutrition counseling using the 5A's of patient-centered counseling, the elements necessary to develop an office-based system and some successful tools developed by nutrition researchers for the primary care setting to be used in an office-based system.
Seeger, John D; Bykov, Katsiaryna; Bartels, Dorothee B; Huybrechts, Krista; Zint, Kristina; Schneeweiss, Sebastian
The RE-LY study demonstrated the safety and efficacy of dabigatran relative to warfarin for stroke prevention in non-valvular atrial fibrillation. It is important to further evaluate safety and effectiveness of drugs in routine care. This study used a sequential cohort design with propensity score matching to compare dabigatran with warfarin among patients in two commercial health insurance databases. New users of these anticoagulants were followed from initiation until discontinuation, the end of the study, or the occurrence of a study outcome (primary study outcomes were stroke and major bleeding). Proportional hazards regression was conducted separately within each data source and results were pooled. Among 19,189 matched dabigatran and warfarin initiators (mean age: 68 years, 36 % female), as-treated follow-up (average of 5 months for dabigatran, 4 months for warfarin) identified 62 and 69 strokes, respectively (pooled HR = 0.77; 95 % CI = 0.54 to 1.09), and 354 and 395 major haemorrhages, respectively (HR = 0.75; 0.65 to 0.87). No meaningful heterogeneity was identified across subgroups, but numeric trends suggest more pronounced stroke prevention by dabigatran relative to warfarin among patients age 75+ (HR = 0.57; 0.33 to 0.97) or with < 6 months of use (HR = 0.51; 0.19 to 1.42). Major bleeds were reduced more by dabigatran among patients aged < 55 (HR = 0.51; 0.30 to 0.87) and with CHADS2 < 2 (HR = 0.58; 0.44 to 0.77). In conclusion, in routine care of patients with non-valvular atrial fibrillation, dabigatran treatment resulted in improved health outcomes compared with warfarin.
Bauer, Amy M.; Collins, Laura; Dugdale, David C.
Abstract Depression is one of the more common diagnoses encountered in primary care, and primary care in turn provides the majority of care for patients with depression. Many approaches have been tried in efforts to improve the outcomes of depression management. This article outlines the partnership between the University of Washington (UW) Neighborhood Clinics and the UW Department of Psychiatry in implementing a collaborative care approach to integrating the management of anxiety and depression in the ambulatory primary care setting. This program was built on the chronic care model, which utilizes a team approach to caring for the patient. In addition to the patient and the primary care provider (PCP), the team included a medical social worker (MSW) as care manager and a psychiatrist as team consultant. The MSW would manage a registry of patients with depression at a clinic with several PCPs, contacting the patients on a regular basis to assess their status, and consulting with the psychiatrist on a weekly basis to discuss patients who were not achieving the goals of care. Any recommendation (eg, a change in medication dose or class) made by the psychiatrist was communicated to the PCP, who in turn would work with the patient on the new recommendation. This collaborative care approach resulted in a significant improvement in the number of patients who achieved care plan goals. The authors believe this is an effective method for health systems to integrate mental health services into primary care. (Population Health Management 2016;19:81–87) PMID:26348355
Fenton, Evelyn; Harvey, Janet; Sturt, Jackie
This paper presents a conceptual framework and tool kit, generated from the evaluation of five primary care research networks (PCRNs) funded by the then London, National Health Service (NHS) Executive. We employed qualitative methods designed to match the most important characteristics of PCRNs, conducting five contextualized case studies covering the five networks. A conceptual evaluation framework based on a review of the organization science literature was developed and comprised the broad, but inter-related organizational dimensions of structure, processes, boundaries and network self-evaluation as input factors and strategic emphasis as epitomized by network objectives. These dimensions were comprised of more detailed subdimensions designed to capture the potential of the networks to create ideas and knowledge, or intellectual capital, the key construct upon which our evaluation tool kit was based. We considered the congruence, or fit, between network objectives and input factors: greater congruence implied greater ability to achieve implicit and overt objectives. We conclude that network evaluation must take place, over time, recognizing stage of development and potential for long-term viability, but within a generic framework of inputs and outputs. If there is a good fit or congruence between their input factors and network objectives, networks will be internally coherent and able to operate at optimum effectiveness.
de Villiers, M
A symposium on Learning in Primary Care was held in Cape Town, South Africa, as a pre-conference workshop to the 9th International Ottawa Conference on Medical Education. The aim of this report is to inform medical educationalists of important issues in learning in primary care and to stimulate further debate. Four international speakers gave presentations on their experiences in teaching and learning in primary care. Objective positive outcome measures include acquiring clinical skills equally well in general practice as in hospital, and improved history taking, physical examination and communication skills learning. Students regard the course as an essential requirement for learning and are appreciative of the wider aspect to learning provided by the community, giving a more holistic view of health. A SWOT analysis (strengths, weaknesses, opportunities and threats) of teaching and learning in primary care identified that learning in primary care is of a generalist nature and reality based, but is hampered by a lack of resources. The increased professionalization of teaching in primary care results in better training, cost containment, and improved quality of health care at community level. It is important to focus on turning threats into opportunities. Academic credibility needs to be established by conducting research on learning in primary care and developing the conceptual basis of primary care.
McGrath, Patrick J.; Feldman, William; Rosser, Walter
The authors describe the major learning problems that confront the primary-care physician. They discuss why they believe that the primary-care physician has an important role in case finding, referral, case management, and advocacy for the child with learning problems and his or her family. PMID:21248891
McGivern, Diane O.; And Others
The baccalaureate nursing program at Herbert H. Lehman College, Bronx, New York prepares students for primary care nursing by structuring the clinical experience to include the essential, interdependent components of: assessment, accountability, leadership, and management. Graduates are expected to be proficient in the primary care role in any…
Fagin, Claire M.
Aspects of the development of medical and nursing education make primary health care just one of medicine's specialities when it is actually the essence of the nursing profession. The author contends that primary care as an academic discipline within nursing is really the general discipline and should be so conceptualized. (MF)
Bezzina, Paul; Keogh, Johann J.; Keogh, Mariana
Nursing and radiology students (n=15) at the University of Malta who completed an interdisciplinary module on primary health care reported they found the theoretical material applicable to practice; the module enabled them to learn about their potential role in primary health care. (SK)
Birt, C A
Basic demographic and epidemiological data relevant to health problems in Vietnam are described in this paper. Existing health service arrangements are referred to, with particular emphasis on the strategy for development of primary health care. The establishment of the paediatric centre in Ho Chi Minh City is reported, and examples of its valuable work in primary health care development are described.
Background Depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting. Methods We used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development. Results Five privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that
Murphy, John W
Primary health care has received a lot of attention since the Alma Ata Conference, convened by the World Health Organization in 1978. Key to the strategy to improve health care outlined at the Alma Ata conference is citizen participation in every phase of service delivery. Although the goals of primary health care have not been achieved, the addition of narrative medicine may facilitate these ends. But a new epistemology is necessary, one that is compatible with narrative medicine, so that local knowledge is elevated in importance and incorporated into the planning, implementation, and evaluation of health programs. In this way, relevant, sustainable, and affordable care can be provided. The aim of this article is to discuss how primary health care might be improved through the introduction of narrative medicine into planning primary health care delivery. PMID:26222094
Ng, Chung Wai Mark; How, Choon How; Ng, Yin Ping
Major depression is a common condition seen in the primary care setting. This article describes the suicide risk assessment of a depressed patient, including practical aspects of history-taking, consideration of factors in deciding if a patient requires immediate transfer for inpatient care and measures to be taken if the patient is not hospitalised. It follows on our earlier article about the approach to management of depression in primary care. PMID:28210741
Lima, Bruno R.
This paper outlines selected differences between the United States and Latin America health care systems as they relate to primary mental health care. It notes that historically both the United States and Latin America have relied on custodial psychiatric hospitals. The alternative of community care for psychiatric patients is described as it is…
... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Comprehensive Primary Care... announces a solicitation for health care payer organizations to participate in the Comprehensive Primary Care initiative (CPC), a multipayer model designed to improve primary care. DATES: Letter of...
King, James R.
The caring and nurturing of children, which characterize primary education culture, have tended to shape a public perception of primary teaching as "women's work." Several social factors influence men's underrepresentation in the profession of primary education, such as parents not wanting their children exposed to "soft"…
Kroese, Mariëlle Elisabeth Aafje Lydia; Spreeuwenberg, Marieke Dingena; Elissen, Arianne Mathilda Josephus; Meerlo, Ronald Johan; Hanraets, Monique Margaretha Henriëtte; Ruwaard, Dirk
Objective: To analyse barriers and facilitators in substituting hospital care with primary care to define preconditions for successful implementation. Methods: A descriptive feasibility study was performed to collect information on the feasibility of substituting hospital care with primary care. General practitioners were able to refer patients, about whom they had doubts regarding diagnosis, treatment and/or the need to refer to hospital care, to medical specialists who performed low-complex consultations at general practitioner practices. Qualitative data were collected through interviews with general practitioners and medical specialists, focus groups and notes from meetings in the Netherlands between April 2013 and January 2014. Data were analysed using a conventional content analysis which resulted in categorised barriers, facilitators and policy adjustments, after which preconditions were formulated. Results: The most important preconditions were make arrangements on governmental level, arrange a collective integrated IT-system, determine the appropriate profile for medical specialists, design a referral protocol for eligible patients, arrange deliberation possibilities for general practitioners and medical specialists and formulate a diagnostic protocol. Conclusions: The barriers, facilitators and formulated preconditions provided relevant input to change the design of substituting hospital care with primary care. PMID:27616956
Campbell, John L; Carter, Mary; Davey, Antoinette; Roberts, Martin J; Elliott, Marc N; Roland, Martin
Background Simulated patient, or so-called ‘mystery-shopper’, studies are a controversial, but potentially useful, approach to take when conducting health services research. Aim To investigate the construct validity of survey questions relating to access to primary care included in the English GP Patient Survey. Design and setting Observational study in 41 general practices in rural, urban, and inner-city settings in the UK. Method Between May 2010 and March 2011, researchers telephoned practices at monthly intervals, simulating patients requesting routine, but prompt, appointments. Seven measures of access and appointment availability, measured from the mystery-shopper contacts, were related to seven measures of practice performance from the GP Patient Survey. Results Practices with lower access scores in the GP Patient Survey had poorer access and appointment availability for five out of seven items measured directly, when compared with practices that had higher scores. Scores on items from the national survey that related to appointment availability were significantly associated with direct measures of appointment availability. Patient-satisfaction levels and the likelihood that patients would recommend their practice were related to the availability of appointments. Patients’ reports of ease of telephone access in the national survey were unrelated to three out of four measures of practice call handling, but were related to the time taken to resolve an appointment request, suggesting responders’ possible confusion in answering this question. Conclusion Items relating to the accessibility of care in a the English GP patient survey have construct validity. Patients’ satisfaction with their practice is not related to practice call handling, but is related to appointment availability. PMID:23561783
Moy, Marilyn L.; Gould, Michael K.; Liu, In-Lu Amy; Lee, Janet S.
The independent relationship between physical inactivity and risk of death after an index chronic obstructive pulmonary disease (COPD) hospitalisation is unknown. We conducted a retrospective cohort study in a large integrated healthcare system. Patients were included if they were hospitalised for COPD between January 1, 2011 and December 31, 2011. All-cause mortality in the 12 months after discharge was the primary outcome. Physical activity, expressed as self-reported minutes of moderate to vigorous physical activity (MVPA), was routinely assessed at outpatient visits prior to hospitalisation. 1727 (73%) patients were inactive (0 min of MVPA per week), 412 (17%) were insufficiently active (1–149 min of MVPA per week) and 231 (10%) were active (≥150 min of MVPA per week). Adjusted Cox regression models assessed risk of death across the MVPA categories. Among 2370 patients (55% females and mean age 73±11 years), there were 464 (20%) deaths. Patients who were insufficiently active or active had a 28% (adjusted HR 0.72 (95% CI 0.54–0.97), p=0.03) and 47% (adjusted HR 0.53 (95% CI 0.34–0.84), p<0.01) lower risk of death, respectively, in the 12 months following an index COPD hospitalisation compared to inactive patients. Any level of MVPA is associated with lower risk of all-cause mortality after a COPD hospitalisation. Routine assessment of physical activity in clinical care would identify persons at high risk for dying after COPD hospitalisation. PMID:27730174
Ghesquiere, Angela R.; Patel, Sapana R.; Kaplan, Daniel B.; Bruce, Martha L.
Objective Bereaved patients are often seen in primary care settings. While most do not require formal support, physicians may be called upon to provide support to some bereaved, particularly those with bereavement-related mental health disorders like complicated grief and bereavement-related depression. Research evidence on physician bereavement care is scant. We make recommendations for future research in this area. Design Literature review, focusing on studies conducted between 1996 and 2013 in the United States. Searches of Medline and PsychInfo, along with hand searches of reference sections, was conducted. Results The limited existing research indicates substantial gaps in the research literature, especially in the areas of primary care physician skill and capacity, patient-level outcomes, and the quality of research methodology. No U.S. studies have focused specifically on care for bereavement-related mental health disorders. We provide recommendations about how to improve research about primary care bereavement care. Conclusions The primary care sector offers ample opportunities for research on bereavement care. With greater research efforts, there may be improvements to quality of bereavement care in primary care, in general, and also to the accurate detection and appropriate referral for bereavement-related mental health conditions. PMID:24955568
Cone, Sharon; Pickler, Rita H.; Grap, Mary Jo; McGrath, Jacqueline; Wiley, Paul M.
Objective To evaluate the effect of four-handed care on preterm infants’ physiologic and behavioral responses to and recovery from endotracheal suctioning versus routine endotracheal (ETT) suctioning. Design Randomized crossover design with infants as their own controls. Setting Single-family-room newborn intensive care unit in an academic health center. Participants Ten intubated infants on conventional ventilation with inline suctioning who were fewer than 37 weeks gestation at birth, and less than one week of age. Methods Each infant was observed twice on a single day. One observation involved routine ETT suctioning and one involved four-handed care. Physiologic and behavioral response data were collected. Results No differences were noted when comparing baseline heart rate (HR) or oxygen saturation (SpO2) data to those obtained during and after suctioning while in the routine care condition. In the four-handed care condition, mean SpO2 increased from preobservation 95.49 to during observation saturation 97.75 (p = .001). Salivary cortisol levels did not differ between groups at baseline or postsuctioning. No significant difference in behavior state was observed between the two conditions. More stress and defense behaviors occurred postsuctioning when infants received routine care as opposed to four-handed care (p = .001) and more self-regulatory behaviors were exhibited by infants during (p = .019) and after suctioning (p = .016) when receiving four-handed care. No statistical difference was found in the number of monitor call-backs postsuctioning. Conclusions Four-handed care during suctioning was associated with a decrease in stress and defense behaviors and an increase in self-regulatory behaviors. PMID:23316894
Snyder, Barbara K; Burack, Gail D; Petrova, Anna
Despite published guidelines on the need to provide comprehensive care to lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) youth, there has been limited research related to the deliverance of primary health care to this population. The goals of this study were to learn about LGBTQ youth's experiences with their primary care physicians and to identify areas for improvement. Youth attending 1 of 5 community-based programs completed a written questionnaire and participated in a focus group discussion regarding experiences at primary care visits, including topics discussed, counselling received, and physician communication. Most of the youth did not feel their health care needs were well met. The majority acknowledged poor patient-provider communication, disrespect, and lack of discussions about important topics such as sexual and emotional health. Participants cited concerns about confidentiality and inappropriate comments as barriers to care. Youth expressed a strong desire to have physicians be more aware of their needs and concerns.
Kilbourne, Amy M; Schulberg, Herbert C; Post, Edward P; Rollman, Bruce L; Belnap, Bea Herbeck; Pincus, Harold Alan
Randomized controlled trials have demonstrated the efficacy and cost-effectiveness of using treatment models for major depression in primary care settings. Nonetheless, translating these models into enduring changes in routine primary care has proved difficult. Various health system and organizational barriers prevent the integration of these models into primary care settings. This article discusses barriers to introducing and sustaining evidence-based depression management services in community-based primary care practices and suggests organizational and financial solutions based on the Robert Wood Johnson Foundation Depression in Primary Care Program. It focuses on strategies to improve depression care in medical settings based on adaptations of the chronic care model and discusses the challenges of implementing evidence-based depression care given the structural, financial, and cultural separation between mental health and general medical care. PMID:15595945
Martínez Riera, José Ramón
Coinciding with the celebration of the 35th anniversary of the journal of nursing, invented in 1977, conducted a systematic review of all issues published (371) to identify items (222) and news (94) related to primary care health. Events are arranged temporarily and refer to accompanying the evolution of primary care model. The Analysis Shows the evolution of primary care, since its inception in 1978, has been reflected in the type of articles and the content of news published, be an excellent indicator of its development and contribution for the nurses.
Bradley-Springer, Lucy; Kang Dufour, Mi-Suk; Koester, Kimberly A.; Beane, Stephanie; Warren, Nancy; Beal, Jeffrey; Frank, Linda Rose
Objectives. We examined the efforts of the US network of AIDS Education and Training Centers (AETCs) to increase HIV testing capacity across a variety of clinical settings. Methods. We used quantitative process data from 8 regional AETCs for July 1, 2008, to June 30, 2009, and qualitative program descriptions to demonstrate how AETC education helped providers integrate HIV testing into routine clinical care with the goals of early diagnosis and treatment. Results. Compared with other AETC training, HIV testing training was longer and used a broader variety of strategies to educate more providers per training. During education, providers were able to understand their primary care responsibility to address public health concerns through HIV testing. Conclusions. AETC efforts illustrate how integration of the principles of primary care and public health can be promoted through professional training. PMID:22515867
Scott, Joan; Trotter, Tracy
With the recent expansion of genetic science, its evolving translation to clinical medicine, and the growing number of available resources for genomics in primary care, the primary care provider must increasingly integrate genetics and genomics into daily practice. Because primary care medicine combines the treatment of acute illness with disease prevention and anticipatory guidance, the primary care provider is in an ideal position to evaluate and treat patients for genetic disease. The notion that genetic knowledge is only rarely needed will have to be replaced with a comprehensive approach that integrates "genetic thinking" into every patient encounter. Genomic competencies will need to be added to the primary care provider's repertoire; such competencies include prevention, assessment, evaluation, and diagnosis of genetic conditions; the ordering and interpreting of genetic tests; communication with families; appropriate referrals; and the management or comanagement of care. The process of deciding when to order genetic tests, what tests to order, and how to interpret the results is complex, and the tests and their results have specific risks and benefits, especially for pediatric patients. The longitudinal nature of primary pediatric care provides the opportunity to obtain and continually update the family history, which is the most powerful initial genetic "test." The ongoing provider-family relationship, coupled with the astounding number of advances in genetic and genomic testing, also necessitates a constant re-evaluation of past diagnosis or nondiagnosis.
Frank, Christopher; Wilson, C. Ruth
Abstract Objective To discuss models of care for frail seniors provided in primary care settings and those developed by Canadian FPs. Sources of information Ovid MEDLINE and the Cochrane database were searched from 2010 to January 2014 using the terms models of care, family medicine, elderly, and geriatrics. Main message New models of funding for primary care have opened opportunities for ways of caring for complex frail older patients. Severity of frailty is an important factor, and more severe frailty should prompt consideration of using an alternate model of care for a senior. In Canada, models in use include integrated care systems, shared care models, home-based care models, and family medicine specialty clinics. No one model should take precedence but FPs should be involved in developing and implementing strategies that meet the needs of individual patients and communities. Organizational and remunerative supports will need to be put in place to achieve widespread uptake of such models. Conclusion Given the increased numbers of frail seniors and the decrease in access to hospital beds, prioritized care models should include ones focused on optimizing health, decreasing frailty, and helping to avoid hospitalization of frail and well seniors alike. The Health Care of the Elderly Program Committee at the College of Family Physicians of Canada is hosting a repository for models of care used by FPs and is asking physicians to submit their ideas for how to best care for frail seniors. PMID:26380850
Tonyan, Holli A.
Eco(logical)-cultural Theory suggests that a daily routine results from individuals adapting cultural ideas to the constraints of a local context or ecology. Using Ecocultural Theory, this research examined family child care providers' descriptions of daily activities and overall approach to understand cultural models. The results highlighted a…
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.
Del Mar, Chris
There is a crisis in primary care health workforce shortages in Australia. Its government has attempted to fix this by role-substitution (replacing medical work with nursing instead). This was not completely successful. Obstacles included entrenched social roles (leading to doctors 'checking' their nurse role-substituted work) and structures (nurses subservient to doctors)--both exacerbated by primary care doctors' ageing demographic; doctors owning their own practices; doctors feeling themselves to have primary responsibility for the care delivered; and greater attraction towards independence that may have selected doctors into primary care in the first place.Yet there is much to be optimistic about this social experiment. It was conducted, if not ideally, at least in an environment that the Australian government has enriched with capacity for research and evaluation.
Bowman, Sarah; Eiserman, Julie; Beletsky, Leo; Stancliff, Sharon; Bruce, R Douglas
Addiction to prescription opioids is prevalent in primary care settings. Increasing prescription opioid use is largely responsible for a parallel increase in overdose nationally. Many patients most at risk for addiction and overdose come into regular contact with primary care providers. Lack of routine addiction screening results in missed treatment opportunities in this setting. We reviewed the literature on screening and brief interventions for addictive disorders in primary care settings, focusing on opioid addiction. Screening and brief interventions can improve health outcomes for chronic illnesses including diabetes, hypertension, and asthma. Similarly, through the use of screening and brief interventions, patients with addiction can achieve improved health outcome. A spectrum of low-threshold care options can reduce the negative health consequences among individuals with opioid addiction. Screening in primary care coupled with short interventions, including motivational interviewing, syringe distribution, naloxone prescription for overdose prevention, and buprenorphine treatment are effective ways to manage addiction and its associated risks and improve health outcomes for individuals with opioid addiction.
Henry, T K
The focus of this article is on recognition of signs and symptoms of pesticide exposure and poisoning in primary care settings. Providers have little problem evaluating clients with an acute exposure to pesticides because the client usually presents with symptoms of poisoning and/or a history of known exposure. The information presented supports the need to consider a history of pesticide exposure in the evaluation of some neurological, dermatologic, reproductive, and other signs and symptoms presented to primary care providers.
Swoboda, W; Hermens, T
Internal medicine specialists involved in primary care will have a leading part in the treatment of geriatric patients with complex healthcare needs in the future. Approved models like specialized geriatric practices, ambulant or mobile geriatric rehabilitation and special geriatric services for nursing homes are available. Essential is a geriatric qualification that fits with the tasks of an internist in primary care. An incentive payment system has to be created for this purpose to improve the treatment of elderly patients.
Date: 8 July 1998 PLACE:The Marriott Hotel, Bristol Date: 9 July 1998 PLACE: Manchester Conference Centre, Manchester Cost: £58.75 (Incl.VAT) These two events provide an opportunity to participate in an open exchange with people experienced in setting up and running primary care groups. There will also be information provided on the ME) Intranet which is a major source of information on primary care groups.
Sorrel, Amy Lynn
The University of North Texas Health Science Center and the Texas College of Osteopathic Medicine are partnering with Midland College and Midland Memorial Hospital to keep their own crop of future doctors in the area. The Primary Care Pathway identifies interested, high-achieving community college students likely to be successful in medical school and guarantees them an accelerated pathway to a doctor of osteopathic medicine degree, focusing earlier and more intensely on primary care.
Vanderlip, Erik R.; Williams, Nancy A.; Fiedorowicz, Jess G.; Katon, Wayne
Background People with serious mental illness often receive inadequate primary and preventive care services. Federal healthcare reform endorses team-based care that provides high quality primary and preventive care to at risk populations. Assertive Community Treatment (ACT) teams offer a proven, standardized treatment approach effective in improving mental health outcomes for the seriously mentally ill. Much is known about the effectiveness of ACT teams in improving mental health outcomes, but the degree to which medical care needs are addressed is not established. Purpose The purpose of this study was to explore the extent to which ACT teams address the physical health of the population they serve. Methods ACT team leaders were invited to complete an anonymous, web-based survey to explore attitudes and activities involving the primary care needs of their clients. Information was collected regarding the use of health screening tools, physical health assessments, provision of medical care and collaboration with primary care systems. Results Data was analyzed from 127 team leaders across the country, of which 55 completed the entire survey. Nearly every ACT team leader believed ACT teams have a role in identifying and managing the medical co-morbidities of their clientele. ACT teams report participation in many primary care activities. Conclusions ACT teams are providing a substantial amount of primary and preventive services to their population. The survey suggests standardization of physical health identification, management or referral processes within ACT teams may result in improved quality of medical care. ACT teams are in a unique position to improve physical health care by virtue of having medically trained staff and frequent, close contact with their clients. PMID:24337472
Pawełczyk, Agnieszka; Pawełczyk, Tomasz; Bielecki, Jan
This paper analyzes and synthesizes the literature on primary care specialty choice. Motivation for choosing medicine and its impact on recruitment to different types of medical work has been presented. Factors that influence medical students and young doctors to change specialty preference have also been explored. Variables, such as gender, martial status, age, income expectations and prestige, that affect medical students' specialty selection decisions for primary care, have been examined. Personality profiles of primary care physician have been evaluated and the influence of communication skills and knowledge of social psychology on his/her work have been analyzed. It is presented that other traits, such as patient-centeredness, needs to serve society and value orientation, is also associated with increases in numbers of students choosing primary care. The analyze shows that the preference for primary care is connected with being interested in diverse patients and health problems and also with being people-orientated. A survey conducted into Polish medical students' attitudes to primary care and family medicine is presented. There is a negative perception of family medicine among Polish students and doctors because of its long work hours and less time for family, insufficient diagnostic possibilities and monotony It is chosen because of lack of other possibilities, difficulties in employment and opportunity to become 'a specialist' in short time.
Phillippi, Julia C; Barger, Mary K
Midwives certified by the American Midwifery Certification Board (AMCB) are prepared to provide primary care to women from menarche across the lifespan and to well newborns to 28 days using consultation, collaboration, and referral to other providers as needed. The scope of midwifery in the United States did not always include primary care for women, although imprecise definitions of primary care make this difficult to study. The expansion of the scope of practice occurred in response to population needs and research on nurse-midwifery practice patterns. The scope of practice of midwifery is tied to educational standards through the regulation and licensure at the state level. Although the current scope of practice includes primary care for women, many certified nurse-midwives and certified midwives are unable to practice to the full extent of their education due to state-level licensure restrictions. We discuss the addition of primary care to midwifery and the current state of AMCB-certified midwives as primary care providers for women.
The approach to treating alcohol-related problems in primary care settings needs: 1) to recognize the incidence of alcohol-related problems in primary care settings; 2) to know the way of screening; 3) to know how to help patients; and 4) to know enough about treating alcoholism to appropriately refer patients for additional help. This article looks research evidence about the incidence of alcohol-related problems in primary care and recognition of incidence and way of screening of alcohol-related problems by primary care physicians in Japan. Then this article describes evidence-based as well as author's experience-based approach to treat the alcohol-related health problems in primary care settings. In line with the newly introduced law to prevent the alcohol-related health problems and the anticipating introduction of new specialty of general medicine, early intervention to alcohol-related problems in primary care settings will be much appreciated. To do so, enough amounts of education and research are needed.
Myers, Martin G.; Kaczorowski, Janusz; Dawes, Martin; Godwin, Marshall
Abstract Objective To provide FPs with detailed knowledge of automated office blood pressure (AOBP) measurement, its potential role in primary care, and its proper use in the diagnosis and management of hypertension. Sources of information Comprehensive monitoring and collection of scientific articles on AOBP by the authors since its introduction. Main message Automated office blood pressure measurement maintains a role for blood pressure (BP) readings taken in the office setting. Clinical research studies have reported a substantially stronger relationship between awake ambulatory BP measurement and AOBP measurement compared with manual BP recorded during routine visits to the patient’s physician. Automated office blood pressure measurement produces mean BP values comparable to awake ambulatory BP and home BP values. Compared with routine manual office BP measurement, AOBP correlates more strongly with awake ambulatory BP measurement, shows less digit preference, is more consistent from visit to visit, is similar both within and outside of the physician’s office, virtually eliminates office-induced hypertension, and is associated with less masked hypertension. It is estimated that more than 25% of Canadian primary care physicians are now using AOBP measurement in their office practices. The use of AOBP to diagnose hypertension has been recommended by the Canadian Hypertension Education Program since 2010. Conclusion There is now sufficient evidence to incorporate AOBP measurement into primary care as an alternative to manual BP measurement. PMID:24522674
Shapira, Stuart K.; Hinton, Cynthia F.; Held, Patrice K.; Jones, Elizabeth; Hannon, W. Harry; Ojodu, Jelili
Routine second screening of most newborns at 8–14 days of life for a panel of newborn conditions occurs in 12 U.S. states, while newborns in the other states typically undergo only a single routine newborn screen. The study objective was to evaluate screening consequences for primary congenital hypothyroidism (CH) in one- and two-screen states according to laboratory practices and medical or biochemical characteristics of screen-positive cases. Individual-level medical and biochemical data were retrospectively collected and analyzed for 2,251 primary CH cases in one-screen (CA, WI) and two-screen (AL, DE, MD, OR, TX) states. Aggregate data were collected and analyzed for medical and biochemical characteristics of all screened newborns in the states. Among the states evaluated in this study, the detection rate of primary CH was higher in the one-screen states. In the two-screen states, 11.5% of cases were detected on the second screen. In multivariate analyses, only race/ethnicity was a significant predictor of cases identified on the first versus second screen, which likely reflects a physiologic difference in primary CH presentation. Newborn screening programs must heed the potential for newborns with CH not being detected by a single screen, particularly newborns of certain races/ethnicities. If the two-screen states converted to a single screen using their current algorithms, newborns currently identified on the routine second screen would presumably not be detected, resulting in probable delayed diagnosis and treatment. However, based on the one-screen state experiences, with appropriate modifications in screening method and algorithm, the two-screen states might convert to single screen operation for CH without loss in performance. PMID:26293295
We do not need a crystal ball to see the future. Our web-based future has already arrived in all other aspects of our lives--even our mobile phones. The tools for progress--Personal Health Records, Social Networks, and Online medical information--are widely available. The demand is at hand--Millennials are flexing consumer muscles as they enter the healthcare market. Real "Health Care Reform" requires fundamental changes in practice--which in turn requires effective use of information technologies and adaption to changing consumer expectations. The VHA and the MHS are uniquely capable of leveraging political, academic and technological forces to help move American health care through this millennial transformation. Federal health systems are positioned to demonstrate the value of innovation as America seeks healthcare reform.
Gutiérrez Pérez, M Isabel; Lucio-Villegas Menéndez, M Eulalia; González, Laura López; Lluch, Natalia Aresté; Morató Agustí, M Luisa; Cachafeiro, Santiago Pérez
Wounds can be classified according to their mechanism of action into surgical or traumatic (which may be incision wounds, such as those provoked by a sharp object; contusions, caused by a blunt force; puncture wounds, caused by long, sharp objects; lacerations, caused by tears to the tissue; or bites, which have a high risk of infection and consequently should not be sutured). Wounds can also be classified by their healing process into acute or chronic (pressure ulcers, vascular ulcers, neuropathic ulcers, acute wounds with torpid clinical course). The use of antiseptics in any of these wounds is usually limited to cleaning and initial care -up to 48 hours- and to washing of hands and instruments. The use of antiseptics in chronic or persistent wounds is more debatable. The same is true of burns, in which the use of formulations that encourage hydration is recommended. In the pediatric population, the use of antiseptics with a known safety profile and low absorption is usually recommended, especially in the care of the umbilical cord, in which evidence supports the use of chlorhexidine gluconate. Another use of antiseptics is the care of wounds produced by procedures used in body esthetics, such as piercings; in these procedures, it is advisable to use transparent antiseptics that allow visualization of the technique.
de Almeida, Patty Fidelis; dos Santos, Adriano Maia
RESUMO OBJECTIVE To analyze the breadth of care coordination by Primary Health Care in three health regions. METHODS This is a quantitative and qualitative case study. Thirty-one semi-structured interviews with municipal, regional and state managers were carried out, besides a cross-sectional survey with the administration of questionnaires to physicians (74), nurses (127), and a representative sample of users (1,590) of Estratégia Saúde da Família (Family Health Strategy) in three municipal centers of health regions in the state of Bahia. RESULTS Primary Health Care as first contact of preference faced strong competition from hospital outpatient and emergency services outside the network. Issues related to access to and provision of specialized care were aggravated by dependence on the private sector in the regions, despite progress observed in institutionalizing flows starting out from Primary Health Care. The counter-referral system was deficient and interprofessional communication was scarce, especially concerning services provided by the contracted network. CONCLUSIONS Coordination capacity is affected both by the fragmentation of the regional network and intrinsic problems in Primary Health Care, which poorly supported in its essential attributes. Although the health regions have common problems, Primary Health Care remains a subject confined to municipal boundaries. PMID:28099663
Fortinsky, Richard H.; Zlateva, Ianita; Delaney, Colleen; Kleppinger, Alison
Purpose: This article explores primary care physicians' (PCPs) self-reported approaches and barriers to management of patients with dementia, with a focus on comparisons in dementia care practices between PCPs in 2 states. Design and Methods: In this cross-sectional study, questionnaires were mailed to 600 randomly selected licensed PCPs in…
Tidman, Michael J
Urticaria is characterised by transient wheals that consist of a swollen palpable centre often surrounded by an erythematous flare, associated with itching or, less commonly, a burning sensation. Individual wheals usually disappear within 1 to 24 hours leaving normal skin. Wheals may be accompanied by angioedema, a more deep-seated flesh-coloured or erythematous swelling of skin or mucous membrane, which may last longer than 24 hours. Urticaria is classified as acute when it resolves within six weeks and chronic when its duration exceeds six weeks. Chronic urticaria is now sub-classified into chronic spontaneous urticaria (CSU) and chronic inducible urticaria. The prognosis for eventual recovery from spontaneous and inducible urticaria is excellent. However, the time course is unpredictable and may extend to years, often following a relapsing and remitting course. Urticaria results from the release of inflammatory mediators from dermal mast cells, resulting in vasodilatation, plasma extravasation, recruitment of immunologically active cells and sensory nerve stimulation. The cause of urticaria cannot usually be precisely identified for most affected individuals. IgE-mediated food allergy is rarely the cause of CSU in patients with the daily appearance of urticarial lesions, although it should be considered in CSU patients with intermittent symptoms. For patients with CSU a differential full blood count and inflammatory markers are all that are routinely recommended. It is also reasonable to test thyroid function and check for circulating thyroid autoantibodies as there is an association between CSU and thyroid autoimmunity.
Mahoney, William J.
Approximately 10% of the population has learning disabilities (LD). Although the main manifestations occur in childhood, many of the primary and secondary manifestations of LD can continue into adult life. The high prevalence of LD and the current economic climate in Canada imply that the primary care physician must have a role in the identification, diagnosis, and management services for persons with LD. Information about the specific aspects of a particular person's LD should be incorporated into the evaluation and management of other health matters with which the primary care physician deals. PMID:21248890
I present a historical study of the role played by the World Health Organization and UNICEF in the emergence and diffusion of the concept of primary health care during the late 1970s and early 1980s. I have analyzed these organizations’ political context, their leaders, the methodologies and technologies associated with the primary health care perspective, and the debates on the meaning of primary health care. These debates led to the development of an alternative, more restricted approach, known as selective primary health care. My study examined library and archival sources; I cite examples from Latin America. PMID:15514221
Bradley, C. P.; Taylor, R. J.; Blenkinsopp, A.
The latest white papers on the NHS focus on stimulating innovation in the delivery of primary care and removing barriers to further development. Some of this innovation relates directly to prescribing in primary care, and in this article the authors speculate on what might happen if the prescribing initiatives referred to in the white papers were extended and disseminated more widely. The initiatives which might have the biggest impact are those encouraging closer collaboration between general practitioners and community pharmacists and those aiding extension of the current nurse prescribing scheme in primary care. Both offer considerable opportunities to improve primary care, but both bear some potential risks. PMID:9116557
Physicians have used computers for years. Although the most popular applications are billing and scheduling software, physicians are increasingly turning to the computer as a tool for medical education. Computers can teach core topics to residents in family medicine and help assess their clinical competence, can help the program director monitor the quality of the educational experience for residents, and can help physicians improve the quality of patient care. Teachers in family medicine can play a role in apprising residents of these developments. PMID:21233941
Grumbach, Kevin; Bodenheimer, Thomas
In health care settings, individuals from different disciplines come together to care for patients. Although these groups of health care personnel are generally called teams, they need to earn true team status by demonstrating teamwork. Developing health care teams requires attention to 2 central questions: who is on the team and how do team members work together? This article chiefly focuses on the second question. Cohesive health care teams have 5 key characteristics: clear goals with measurable outcomes, clinical and administrative systems, division of labor, training of all team members, and effective communication. Two organizations are described that demonstrate these components: a private primary care practice in Bangor, Me, and Kaiser Permanente's Georgia region primary care sites. Research on patient care teams suggests that teams with greater cohesiveness are associated with better clinical outcome measures and higher patient satisfaction. In addition, medical settings in which physicians and nonphysician professionals work together as teams can demonstrate improved patient outcomes. A number of barriers to team formation exist, chiefly related to the challenges of human relationships and personalities. Taking small steps toward team development may improve the work environment in primary care practices.
Horton, T C; Jackson, R; Mohan, N; Hambidge, J E
It was hypothesised that routine splintage following primary total knee replacement has no affect on flexion deformity and offers no benefit over simple wool and crepe. Fifty-five patients undergoing primary total knee replacement were entered into a prospective study. The patients were randomly assigned to two groups: The first group was rehabilitated without a splint and the second received an adjustable semi-rigid extension splint (Richards splint) for the first 48 h after surgery. Range of motion measurements were recorded pre-operatively and at 2 days, 1 week and 3 months post-operation by a research nurse blinded to the allocation. No statistically significant difference in flexion deformity was found at any stage (P>0.5). No difference was found in general or wound complications, or requirement for blood transfusion, and the post-operative stay was equal in the two groups. We conclude that routine use of a semi-rigid splint following primary total knee replacement has no advantage over simple wound dressings.
Barakat-Haddad, C; Siddiqua, A
This study examined primary health care use and accessibility among adolescents living in the United Arab Emirates. In a cross-sectional study, we collected health care use, sociodemographic and residential data for a sample of 6363 adolescents. Logistic regression modelling was used to examine predictors of health care use. The most-consulted health professionals were dentists or orthodontists, family doctors and eye specialists. Local adolescents were more likely to attend public clinics/hospitals than private facilities, while the opposite was true for expatriates. In the previous 12 months 22.6% of the participants had not obtained the health care they needed and 19.5% had not had a routine health check-up. Common reasons for not obtaining care were busy schedules, dislike/fear of doctors and long waiting times. Predictors of not obtaining needed care included nationality and income, while those for having a routine check-up were mother's education and car ownership. Improvements to the health care sector may increase health care accessibility among adolescents.
McLeod, Logan; Buckley, Gioia; Sweetman, Arthur
Background: Between 2001 and 2006, the Ontario government introduced a menu of new primary care models, with elements such as patient enrolment and minimum group sizes, and various combinations of fee-for-service, capitation, pay-for-performance and salary. From the statistical perspective of physicians, as opposed to patients, we looked at the distribution of physician characteristics, group size and patient visit patterns across models to describe primary care practice in Ontario. Methods: Using administrative data for fiscal year 2010/11 containing information on physician characteristics, patient rostering status, patient visits and other practice information, we described similarities and differences across primary care models. Results: Our sample included 11 626 family physicians. Compared with physicians in the new primary care models, physicians in fee-for-service models are much more likely to work part-time and many, particularly younger and female physicians, do not work in full-year full-scope practices. Among the new primary care models, physicians in capitated models are slightly younger, are less likely to be an international medical graduate, work in smaller physician teams and do not practice in urban areas. On average, physicians saw and rostered 1888 patients. Although there is still substantial variation within each model, fee-for-service physicians saw the fewest patients; physicians in capitated models saw somewhat more, and those in the noncapitated models saw the most patients. Interpretation: Practice and physician characteristics vary systematically across models. A high percentage of rostered patients see physicians outside the group with which they are rostered. Group-based primary care models may not have a large impact on group integration and continuity in the provision of primary care services. PMID:28018882
Hallgren Elfgren, Ing-Marie; Grodzinsky, Ewa; Törnvall, Eva
Aim The purpose of this project is to describe the use of the Swedish National Diabetes Register (NDR) in clinical practice in a Swedish county and to specifically monitor the diabetes care routines at two separate primary health-care centres (PHCC) with a special focus on older patients.
Shakeshaft, Anthony; Fawcett, Julia; Mattick, Richard P.; Richmond, Robyn; Wodak, Alex; Harris, Mark F.; Doran, Christopher M.
Purpose: The purpose of this research is to explore the feasibility of using patient-driven, hand-held computers in primary care settings, in order to address the apparent failure to implement prevention initiatives into the routine delivery of health care services. Design/methodology/approach: During an eight-day period, patients of an English…
Funderburk, Jennifer S.; Shepardson, Robyn L.; Krenek, Marketa
Objective: To describe how behavioral activation (BA) for depression and stimulus control (SC) for insomnia can be modified to a brief format for use in a university primary care setting, and to evaluate preliminarily their effectiveness in reducing symptoms of depression and insomnia, respectively, using data collected in routine clinical care.…
Riley, Anthony J; Harding, Geoffrey; Underwood, Martin R; Carter, Yvonne H
Homelessness is a social problem that affects all facets of contemporary society. This paper discusses the concept of homelessness in terms of its historical context and the dominance of the pervasive 'victim blaming' ideologies, which, together with the worldwide economic changes that have contributed to a fiscal crisis of the state, and the resultant policies and circumstances, have led to an increase in the number of 'new homeless' people. This paper attempts to challenge the dominant political discourse on homelessness. The widespread healthcare problems and heterogeneity of homeless people have a particular impact on health services, with many homeless people inappropriately accessing local accident and emergency (A&E) departments because of barriers inhibiting adequate access to primary care. A number of primary care schemes have been successfully implemented to enable the homeless to have better access to appropriate care. However, there is no consistency in the level of services around the United Kingdom (UK), and innovations in service are not widespread and by their nature they are ad hoc. Despite the successes of such schemes, many homeless people still access health care inappropriately. Until homeless people are fully integrated into primary care the situation will not change. The question remains, how can appropriate access be established? A start can be made by building on some of the positive work that is already being done in primary care, but in reality general practitioners (GPs) will be 'swimming against the tide' unless a more integrated policy approach is adopted to tackle homelessness.
Riley, Anthony J; Harding, Geoffrey; Underwood, Martin R; Carter, Yvonne H
Homelessness is a social problem that affects all facets of contemporary society. This paper discusses the concept of homelessness in terms of its historical context and the dominance of the pervasive 'victim blaming' ideologies, which, together with the worldwide economic changes that have contributed to a fiscal crisis of the state, and the resultant policies and circumstances, have led to an increase in the number of 'new homeless' people. This paper attempts to challenge the dominant political discourse on homelessness. The widespread healthcare problems and heterogeneity of homeless people have a particular impact on health services, with many homeless people inappropriately accessing local accident and emergency (A&E) departments because of barriers inhibiting adequate access to primary care. A number of primary care schemes have been successfully implemented to enable the homeless to have better access to appropriate care. However, there is no consistency in the level of services around the United Kingdom (UK), and innovations in service are not widespread and by their nature they are ad hoc. Despite the successes of such schemes, many homeless people still access health care inappropriately. Until homeless people are fully integrated into primary care the situation will not change. The question remains, how can appropriate access be established? A start can be made by building on some of the positive work that is already being done in primary care, but in reality general practitioners (GPs) will be 'swimming against the tide' unless a more integrated policy approach is adopted to tackle homelessness. PMID:12939894
Casalino, Lawrence P.; Chen, Melinda A.; Staub, C. Todd; Press, Matthew J.; Mendelsohn, Jayme L.; Lynch, John T.; Miranda, Yesenia
PURPOSE In the turbulent US health care environment, many primary care physicians seek hospital employment. Large physician-owned primary care groups are an alternative, but few physicians or policy makers realize that such groups exist. We wanted to describe these groups, their advantages, and their challenges. METHODS We identified 21 groups and studied 5 that varied in size and location. We conducted interviews with group leaders, surveyed randomly selected group physicians, and interviewed external observers—leaders of a health plan, hospital, and specialty medical group that shared patients with the group. We triangulated responses from group leaders, group physicians, and external observers to identify key themes. RESULTS The groups’ physicians work in small practices, with the group providing economies of scale necessary to develop laboratory and imaging services, health information technology, and quality improvement infrastructure. The groups differ in their size and the extent to which they engage in value-based contracting, though all are moving to increase the amount of financial risk they take for their quality and cost performance. Unlike hospital-employed and multispecialty groups, independent primary care groups can aim to reduce health care costs without conflicting incentives to fill hospital beds and keep specialist incomes high. Each group was positively regarded by external observers. The groups are under pressure, however, to sell to organizations that can provide capital for additional infrastructure to engage in value-based contracting, as well as provide substantial income to physicians from the sale. CONCLUSIONS Large, independent primary care groups have the potential to make primary care attractive to physicians and to improve patient care by combining human scale advantages of physician autonomy and the small practice setting with resources that are important to succeed in value-based contracting. PMID:26755779
Durán-Arenas, Luis; Salinas-Escudero, Guillermo; Granados-García, Víctor; Martínez-Valverde, Silvia
Access to health services is a social basic determinant of health in Mexico unlike what happens in developed countries. The demand for health services is focused on primary care, but the design meets only the supply of hospital care services. So it generates a dissonance between the needs and the effective design of health services. In addition, the term affiliation refers to population contributing or in the recruitment process, that has been counted as members of these social security institutions (SS) and Popular Insurance (SP). In the case of Instituto Mexicano del Seguro Social (IMSS) three of four contributors are in contact with health services; while in the SP, this indicator does not exist. Moreover, the access gap between health services is found in the health care packages so that members of the SS and SP do not have same type of coverage. The question is: which model of health care system want the Mexicans? Primary care represents the first choice for increasing the health systems performance, as well as to fulfill their function of social protection: universal access and coverage based on needs, regardless whether it is a public or private health insurance. A central aspect for development of this component is the definition of the first contact with the health system through the creation of a primary health care team, led by a general practitioner as the responsible of a multidisciplinary health team. The process addresses the concepts of primary care nursing, consumption of inputs (mainly medical drugs), maintenance and general services. Adopting a comprehensive strategy that will benefit all Mexicans equally and without discrimination, this primary care system could be financed with a total operating cost of approximately $ 22,809 million by year.
Valecha, Gautam; Pau, Dhaval; Nalluri, Nikhil; Liu, Ying; Mohammad, Farhan; Atallah, Jean Paul
Cardiac sarcomas are extremely rare primary malignant tumors of the heart. In this article, we present the case of a 70-year-old female, who was found to have a left atrial mass during a routine outpatient transthoracic echocardiography. Further investigation with cardiac magnetic resonance imaging confirmed the presence of a bilobulated mass with heterogeneous enhancement. Left atrial myxoma was the first diagnostic consideration, followed by other primary cardiac tumors, and thrombus. The patient subsequently underwent resection of the mass, utilizing cardiopulmonary bypass. Upon pathological examination, the mass was found to be an intimal sarcoma. The objective of this report is to describe a case of this rare disease entity, and to discuss its presentation, pathological findings and management. PMID:27994830
The primary health care team at present does not include social workers as routine members. If however, we, accept the World Health Organization definition of health, which includes social well being, then it follows that the social worker should be considered as a member of the health team to attend to this aspect of health in the service delivery mix. This paper presents the experience of a social worker assigned to the August Town/Hermitage Type III health centre during the period March 1995 to February 1996 and her contribution to patient welfare. The expected roles of the social worker and his or her contribution to the health team are outlined.
Munns, Ailsa; Forde, Karen A; Krouzecky, Miriam; Shields, Linda
Within the current Australian health system is the understanding of a need to change from the predominate biomedical model to incorporate a comprehensive primary health care centred approach, embracing the social contexts of health and wellbeing. Recent research investigated the benefits of the primary health care philosophy and strategies in relation to the Rainbows programme which addresses grief and loss in primary school aged students in Western Australia. A multidisciplinary collaboration between the Western Australian Departments of Health and Education enabled community school health nurse coordinators to train teacher facilitators in the implementation of Rainbows, enabling support for students and their parents. The results of this qualitative study indicate that all participants regard Rainbows as effective, with many perceived benefits to students and their families.
Kwitkowski, V E; Demko, S G
Infectious disease emergencies can be described as infectious processes that, if not recognized and treated immediately, can lead to significant morbidity or mortality. These emergencies can present as common or benign infections, fooling the primary care provider into using more conservative treatment strategies than are required. This review discusses the pathophysiology, history and physical findings, diagnostic criteria, and treatment strategies for the following infectious disease emergencies: acute bacterial meningitis, ehrlichiosis, Rocky Mountain spotted fever, meningococcemia, necrotizing soft tissue infections, toxic shock syndrome, food-borne illnesses, and infective endocarditis. Because most of the discussed infectious disease emergencies require hospital care, the primary care clinician must be able to judge when a referral to a specialist or a higher-level care facility is indicated.
Rushing, Jona M.; Jones, Laura E.; Carney, Caroline P.
Bulimia nervosa is a psychiatric condition that affects many adolescent and young adult women. The disorder is characterized by bingeing and purging behavior and can lead to medical complications. Thus, patients with bulimia nervosa commonly present in the primary care setting. Physical and laboratory examinations reveal markers of bulimia nervosa that are useful in making the diagnosis. Treatment is beneficial, and outcomes of early intervention are good. This article discusses the history, presentation, and tools needed for recognizing and treating bulimia nervosa in primary care. PMID:15213788
Eigenmann, Philippe A
Primary care physicians will conduct allergy diagnosis based on the history provided by the patient. In case of a possible IgE type allergy, investigations will be made by skin tests or measurement of specific IgE antibodies in the serum. Interpretation of positive tests will have to consider possible sensitizations in absence of allergic symptoms that should not lead to inadequate therapeutic measures or diet. This review will provide to primary care physicians guidance to choose the best method in the appropriate situations for allergy diagnosis.
There are a number of significant diseases among cultured and free-ranging freshwater fishes that have a bacterial etiology; these represent a variety of gram-negative and gram-positive genera. Confirmatory diagnosis of these diseases involves primary isolation of the causative bacterium on bacteriologic media. Frequently used "general" bacteriologic media simply provide the essential nutrients for growth. For most of the major pathogens, however, there are differential and/or selective media that facilitate primary recovery. Some specialized media are available as "ready-to-use" from suppliers, while others must be prepared. Differential media employ various types of indicator systems, such as pH indicators, that allow diagnosticians to observe assimilation of selected substrates. An advantage to the use of differential media for primary isolation is that they hasten bacterial characterization by yielding the appropriate positive or negative result for a particular substrate, often leading to a presumptive identification. Selective media also incorporate agent(s) that inhibit the growth of contaminants typically encountered with samples from aquatic environments. Media that incorporate differential and/or selective components are ideally based on characters that are unique to the targeted bacterium, and their use can reduce the time associated with diagnosis and facilitate early intervention in affected fish populations. In this review, the concepts of general and differential/selective bacteriologic media and their use and development for fish pathogens are discussed. The media routinely employed for primary isolation of the significant bacterial pathogens of fishes are presented. ?? Wildlife Disease Association 2008.
Jiang, Li; Lofters, Aisha; Moineddin, Rahim; Decker, Kathleen; Groome, Patti; Kendell, Cynthia; Krzyzanowska, Monika; Li, Dongdong; McBride, Mary L.; Mittmann, Nicole; Porter, Geoff; Turner, Donna; Urquhart, Robin; Winget, Marcy; Zhang, Yang; Grunfeld, Eva
Abstract Objective To describe primary care physician (PCP) use and continuity of PCP care across the breast cancer care continuum. Design Population-based, retrospective cohort study using provincial cancer registries linked to health administrative databases. Setting British Columbia, Manitoba, and Ontario. Participants All women with incident invasive breast cancer from 2007 to 2012 in Manitoba and Ontario and from 2007 to 2011 in British Columbia. Main outcome measures The number and proportions of visits to PCPs were determined. Continuity of care was measured using the Usual Provider of Care index calculated as the proportion of visits to the most-often-visited PCP in the 6 to 30 months before a breast cancer diagnosis (baseline) and from 1 to 3 years following a breast cancer diagnosis (survivorship). Results More than three-quarters of patients visited their PCPs 2 or more times during the breast cancer diagnostic period, and more than 80% of patients had at least 1 PCP visit during breast cancer adjuvant treatment. Contact with the PCP decreased over time during breast cancer survivorship. Of the 3 phases, women appeared to be most likely to not have PCP contact during adjuvant treatment, with 10.7% (Ontario) to 18.7% (British Columbia) of women having no PCP visits during this phase. However, a sizable minority of women had at least monthly visits during the treatment phase, particularly in Manitoba and Ontario, where approximately a quarter of women saw a PCP at least monthly. We observed higher continuity of care with PCPs in survivorship (compared with baseline) in all provinces. Conclusion Primary care physicians were generally involved throughout the breast cancer care continuum, but the level of involvement varied across care phases and by province. Future interventions will aim to further integrate primary and oncology care. PMID:27737994
Wint, Amy J.; Smeltzer, Suzanne C.; Ecker, Jeffrey L.
Abstract Background: Routine prenatal care includes physical examinations and weight measurement. Little is known about whether access barriers to medical diagnostic equipment, such as examination tables and weight scales, affect prenatal care among pregnant women with physical disabilities. Methods: We conducted 2-hour, in-depth telephone interviews with 22 women using a semistructured, open-ended interview protocol. All women had significant mobility difficulties before pregnancy and had delivered babies within the prior 10 years. We recruited most participants through social networks. We sorted interview transcript texts using used NVivo software and conducted conventional content analyses to identify major themes. Results: Interviewee's mean (standard deviation) age was 34.8 (5.3) years. Most were white, well-educated, and higher income; 8 women had spinal cord injuries, 4 cerebral palsy, and 10 had other conditions; 18 used wheeled mobility aids. Some women's obstetricians had height adjustable examination tables, which facilitated transfers for physical examinations. Other women had difficulty transferring onto fixed height examination tables and were examined while sitting in their wheelchairs. Family members and/or clinical staff sometimes assisted with transfers; some women reported concerns about transfer safety. No women reported being routinely weighed on an accessible weight scale by their prenatal care clinicians. A few were never weighed during their pregnancies. Conclusions: Inaccessible examination tables and weight scales impede some pregnant women with physical disabilities from getting routine prenatal physical examinations and weight measurement. This represents substandard care. Adjustable height examination tables and wheelchair accessible weight scales could significantly improve care and comfort for pregnant women with physical disabilities. PMID:26484689
Robinson, Maisha T.; Holloway, Robert G.
Abstract Purpose of review: To present current knowledge and recommendations regarding communication tasks and practice approaches for neurologists as they practice primary palliative care, including discussing serious news, managing symptoms, aligning treatment with patient preferences, introducing hospice/terminal care, and using the multiprofessional approach. Recent findings: Neurologists receive little formal palliative care training yet often need to discuss prognosis in serious illness, manage intractable symptoms in chronic progressive disease, and alleviate suffering for patients and their families. Because patients with neurologic disorders often have major cognitive impairment, physical impairment, or both, with an uncertain prognosis, their palliative care needs are particularly challenging and they remain largely uncharacterized and often unmanaged. Summary: We provide an overview of neuropalliative care as a fundamental skill set for all neurologists. PMID:26918202
Lymbery, M; Millward, A
This paper examines the establishment of social work within primary health care settings in Great Britain, following the passage of the National Health Service and Community Care Act in 1990. Although the improvement of relationships between social workers and primary health care teams has been promoted for a number of years, the advent of formal policies for community care has made this a priority for both social services and health. This paper presents interim findings from the evaluation of three pilot projects in Nottinghamshire, Great Britain. These findings are analysed from three linked perspectives. The first is the extent to which structures and organisations have worked effectively together to promote the location of social workers within health care settings. The second is the impact of professional and cultural factors on the work of the social worker in these settings. The third is the effect of interpersonal relationships on the success of the project. The paper will conclude that there is significant learning from each of these perspectives which can be applied to the future location of social workers to primary health care.
Gallagher, Niamh; MacFarlane, Anne; Murphy, Andrew W; Freeman, George K; Glynn, Liam G; Bradley, Colin P
Modernization policies in primary care, such as the introduction of out-of-hours general practice cooperatives, signify a marked departure from many service users' traditional experiences of continuity of care. We report on a case study of accounts of service users with chronic conditions and their caregivers of continuity of care in an out-of-hours general practice cooperative in Ireland. Using Strauss and colleagues' Chronic Illness Trajectory Framework, we explored users' and caregivers' experiences of continuity in this context. Whereas those dealing with "routine trajectories" were largely satisfied with their experiences, those dealing with "problematic trajectories" (characterized by the presence of, for example, multimorbidity and complex care regimes) had considerable concerns about continuity of experiences in this service. Results highlight that modernization policies that have given rise to out-of-hours cooperatives have had a differential impact on service users with chronic conditions and their caregivers, with serious consequences for those who have "problematic" trajectories.
Sullivan, William F.; Berg, Joseph M.; Bradley, Elspeth; Cheetham, Tom; Denton, Richard; Heng, John; Hennen, Brian; Joyce, David; Kelly, Maureen; Korossy, Marika; Lunsky, Yona; McMillan, Shirley
Abstract Objective To update the 2006 Canadian guidelines for primary care of adults with developmental disabilities (DD) and to make practical recommendations based on current knowledge to address the particular health issues of adults with DD. Quality of evidence Knowledgeable health care providers participating in a colloquium and a subsequent working group discussed and agreed on revisions to the 2006 guidelines based on a comprehensive review of publications, feedback gained from users of the guidelines, and personal clinical experiences. Most of the available evidence in this area of care is from expert opinion or published consensus statements (level III). Main message Adults with DD have complex health issues, many of them differing from those of the general population. Good primary care identifies the particular health issues faced by adults with DD to improve their quality of life, to improve their access to health care, and to prevent suffering, morbidity, and premature death. These guidelines synthesize general, physical, behavioural, and mental health issues of adults with DD that primary care providers should be aware of, and they present recommendations for screening and management based on current knowledge that practitioners can apply. Because of interacting biologic, psychoaffective, and social factors that contribute to the health and well-being of adults with DD, these guidelines emphasize involving caregivers, adapting procedures when appropriate, and seeking input from a range of health professionals when available. Ethical care is also emphasized. The guidelines are formulated within an ethical framework that pays attention to issues such as informed consent and the assessment of health benefits in relation to risks of harm. Conclusion Implementation of the guidelines proposed here would improve the health of adults with DD and would minimize disparities in health and health care between adults with DD and those in the general population
Beasley, J W; Hahn, D L; Wiesen, P; Plane, M B; Manwell, L
A significant portion of research project costs is incurred before the receipt of grant funds. This poses a problem for the initiation of primary care research, especially in community practice settings. Potential investigators need financial support for staff time, training, pilot work, and grant proposal writing if primary care researchers are to compete successfully for grant funds. To find this support, we need to understand and eventually quantify the actual costs of research with attention to those that are incurred before the receipt of grant funds. We outline 10 phases of the research process and provide a model for understanding where costs are incurred and by whom. Costs include those associated with maintaining practice interest in research, supporting practice participation, and disseminating research findings. They may be incurred by either an academic center or a research network, by the practices and physicians themselves, or by an extramural funding source. The needed investment for initiating primary care research can be itemized and, with further research, quantified. This will enhance the arguments for capital investments in the primary care research enterprise.
Council of Europe, Strasbourg (France).
This report examines the possiblities of increasing the amount of preventive work being carried out by primary care workers in European communities. Before making practical recommendations about promoting prevention, an analysis is presented of the main present day problems. These center on the environment (not only physical but also social and…
Lan, Jia; Chang, Chiang-hua; Goodman, David C.
OBJECTIVES: This study examines growth in the primary care physician workforce for children and examines the geographic distribution of the workforce. METHODS: National data were used to calculate the local per-capita supply of clinically active general pediatricians and family physicians, measured at the level of primary care service areas. RESULTS: Between 1996 and 2006, the general pediatrician and family physician workforces expanded by 51% and 35%, respectively, whereas the child population increased by only 9%. The 2006 per-capita supply varied by >600% across local primary care markets. Nearly 15 million children (20% of the US child population) lived in local markets with <710 children per child physician (average of 141 child physicians per 100 000 children), whereas another 15 million lived in areas with >4400 children per child physician (average of 22 child physicians per 100 000 children). In addition, almost 1 million children lived in areas with no local child physician. Nearly all 50 states had evidence of similar extremes of physician maldistribution. CONCLUSIONS: Undirected growth of the aggregate child physician workforce has resulted in profound maldistribution of physician resources. Accountability for public funding of physician training should include efforts to develop, to use, and to evaluate policies aimed at reducing disparities in geographic access to primary care physicians for children. PMID:21172992
Diallo, I; Molouba, R; Sarr, L C
A review is presented of Senegal's response to the Bamako Initiative, aimed at strengthening primary health care. The experience gained is of broad interest since the basic principles involved are the same everywhere. Of particular importance are users' financial contributions and improved organization and management.
Macinko, James; Montenegro, Hernán; Nebot Adell, Carme; Etienne, Carissa
At the 2003 meeting of the Directing Council of the Pan American Health Organization (PAHO), the PAHO Member States issued a mandate to strengthen primary health care (Resolution CD44. R6). The mandate led in 2005 to the document "Renewing Primary Health Care in the Americas. A Position Paper of the Pan American Health Organization/WHO [World Health Organization]," and it culminated in the Declaration of Montevideo, an agreement among the governments of the Region of the Americas to renew their commitment to primary health care (PHC). Scientific data have shown that PHC, regarded as the basis of all the health systems in the Region, is a key component of effective health systems and can be adapted to the range of diverse social, cultural, and economic conditions that exist. The new, global health paradigm has given rise to changes in the population's health care needs. Health services and systems must adapt to address these changes. Building on the legacy of the International Conference on Primary Health Care, held in 1978 in Alma-Ata (Kazakhstan, Union of Soviet Socialist Republics), PAHO proposes a group of strategies critical to adopting PHC-based health care systems based on the principles of equity, solidarity, and the right to the highest possible standard of health. The main objective of the strategies is to develop and/or strengthen PHC-based health systems in the entire Region of the Americas. A substantial effort will be required on the part of health professionals, citizens, governments, associations, and agencies. This document explains the strategies that must be employed at the national, subregional, Regional, and global levels.
Sibbald, Bonnie; Laurant, Miranda G; Reeves, David
Nurses increasingly work as substitutes for, or to complement, general practitioners in the care of minor illness and the management of chronic diseases. Available research suggests that nurses can provide as high quality care as GPs in the provision of first contact and ongoing care for unselected patients. Reductions in cost are context dependent and rarely achieved. This is because savings on nurses' salaries are often offset by their lower productivity (due to longer consultations, higher patient recall rates, and increased use of tests and investigations). Gains in efficiency are not achieved when GPs continue to provide the services that have been delegated to nurses, instead of focusing on the services that only doctors can provide. Unintended consequences of extending nursing roles include loss of personal continuity of care for patients and increased difficulties with coordination of care as the multidisciplinary team size increases. Rapid access to care is, however, improved. There is a high capital cost involved in moving to multidisciplinary teams because of the need to train staff in new ways of working; revise legislation governing scope of practice; address concerns about legal liability; and manage professional resistance to change. Despite the unintended consequences and the high costs, extending nursing roles in primary care is a plausible strategy for improving service capacity without compromising quality of care or health outcomes for patients.
Primary care serves as the cornerstone in a strong healthcare system. However, it has long been overlooked in the United States (USA), and an imbalance between specialty and primary care exists. The objective of this focused review paper is to identify research evidence on the value of primary care both in the USA and internationally, focusing on the importance of effective primary care services in delivering quality healthcare, improving health outcomes, and reducing disparities. Literature searches were performed in PubMed as well as “snowballing” based on the bibliographies of the retrieved articles. The areas reviewed included primary care definitions, primary care measurement, primary care practice, primary care and health, primary care and quality, primary care and cost, primary care and equity, primary care and health centers, and primary care and healthcare reform. In both developed and developing countries, primary care has been demonstrated to be associated with enhanced access to healthcare services, better health outcomes, and a decrease in hospitalization and use of emergency department visits. Primary care can also help counteract the negative impact of poor economic conditions on health. PMID:24278694
Weisner, Constance; Mertens, Jennifer; Parthasarathy, Sujaya; Moore, Charles; Lu, Yun
Context The prevalence of medical disorders is high among substance abuse patients, yet medical services are seldom provided in coordination with substance abuse treatment. Objective To examine differences in treatment outcomes and costs between integrated and independent models of medical and substance abuse care as well as the effect of integrated care in a subgroup of patients with substance abuse–related medical conditions (SAMCs). Design Randomized controlled trial conducted between April 1997 and December 1998. Setting and Patients Adult men and women (n=592) who were admitted to a large health maintenance organization chemical dependency program in Sacramento, Calif. Interventions Patients were randomly assigned to receive treatment through an integrated model, in which primary health care was included within the addiction treatment program (n=285), or an independent treatment-as-usual model, in which primary care and substance abuse treatment were provided separately (n=307). Both programs were group based and lasted 8 weeks, with 10 months of aftercare available. Main Outcome Measures Abstinence outcomes, treatment utilization, and costs 6 months after randomization. Results Both groups showed improvement on all drug and alcohol measures. Overall, there were no differences in total abstinence rates between the integrated care and independent care groups (68% vs 63%, P=.18). For patients without SAMCs, there were also no differences in abstinence rates (integrated care, 66% vs independent care, 73%; P=.23) and there was a slight but nonsignificant trend of higher costs for the integrated care group ($367.96 vs $324.09, P=.19). However, patients with SAMCs (n=341) were more likely to be abstinent in the integrated care group than the independent care group (69% vs 55%, P=.006; odds ratio [OR], 1.90; 95% confidence interval [CI], 1.22-2.97). This was true for both those with medical (OR, 3.38; 95% CI, 1.68-6.80) and psychiatric (OR, 2.10; 95% CI, 1
Young, Heather M; Nesbitt, Thomas S
Primary care is the foundation of effective and high-quality health care. The role of primary care clinicians has expanded to encompass coordination of care across multiple providers and management of more patients with complex conditions. Enabling technology has the potential to expand the capacity for primary care clinicians to provide integrated, accessible care that channels expertise to the patient and brings specialty consultations into the primary care clinic. Furthermore, technology offers opportunities to engage patients in advancing their health through improved communication and enhanced self-management of chronic conditions. This paper describes enabling technologies in four domains (the body, the home, the community, and the primary care clinic) that can support the critical role primary care clinicians play in the health care system. It also identifies challenges to incorporating these technologies into primary care clinics, care processes, and workflow.
Lewin, Warren H; Schaefer, Kristen G
Heart failure (HF) affects nearly 5.7 million Americans and is described as a chronic incurable illness carrying a poor prognosis. Patients living with HF experience significant symptoms including dyspnea, pain, anxiety, fatigue, and depression. As the illness advances into later stages, symptoms become more intense and refractory to standard treatments, leading to recurrent acute-care utilization and contributing to poor quality of life. Advanced HF symptoms have been described to be as burdensome, if not more than, those in cancer populations. Yet access to and provision of palliative care (PC) for this population has been described as suboptimal. The Institute of Medicine recently called for better access to PC for seriously ill patients. Despite guidelines recommending the inclusion of PC into the multidisciplinary HF care team, there is little data offering guidance on how to best operationalize PC skills in caring for this population. This paper describes the emerging literature describing models of PC integration for HF patients and aims to identify key attributes of these care models that may help guide future multi-site clinical trials to define best practices for the successful delivery of PC for patients living with advanced HF.
Laux, Gunter; Walther, Winfried
Background Little is known about the differences of rotary multiple file endodontic therapy and single-file reciprocating endodontic treatment under routine care conditions in dental practice. This multicenter study was performed to compare the outcome of multiple-file (MF) and single-file (SF) systems for primary root canal treatment under conditions of general dental practice regarding reduction of pain with a visual analogue scale (VAS 100), improvement of oral-health-related quality of life (OHRQoL) with the german short version of the oral health impact profile (OHIP-G-14) and the speed of root canal preparation. Materials and Methods Ten general dental practitioners (GDPs) participated in the study as practitioner-investigators (PI). In the first five-month period of the study, the GDPs treated patients with MF systems. After that, the GDPs treated the patients in the second five-month period with a SF system (WaveOne). The GDPs documented the clinical findings at the beginning and on completion of treatment. The patients documented their pain and OHRQoL before the beginning and before completion of treatment. Results A total of 599 patients were included in the evaluation. 280 patients were in the MF group, 319 were in the SF WaveOne group. In terms of pain reduction and improvement in OHIP-G-14, the improvement in both study groups (MF and SF) was very similar based on univariate analysis methods. Pain reduction was 34.4 (SD 33.7) VAS (MF) vs. 35.0 (SD 35.4) VAS (SF) (p = 0.840) and the improvement in OHIP-G-14 score was 9.4 (SD 10.3) (MF) vs. 8.5 (SD 10.2) (SF) (p = 0.365). The treatment time per root canal was 238.9 s (SD 206.2 s) (MF) vs. 146.8 sec. (SD 452.8 sec) (SF) (p = 0.003). Discussion Regarding improvement of endodontic pain and OHRQoL measure with OHIP-G-14, there were no statistical significant differences between the SF und the MF systems. WaveOne-prepared root canals significantly faster than MF systems. PMID:27957398
McInerney, Joseph D.
The family history has been called the first genetic test; it was a core element of primary care long before the current wave of genetics technologies and services became clinically relevant. Risk assessment based on family history allows providers to personalize and prioritize health messages, shifts the focus of health care from treatment to prevention, and can empower individuals and families to be stewards of their own health. In a world of rising health care costs, the family history is an important tool, with its primary cost being the clinician’s time. However, a recent National Institutes of Health conference highlighted the lack of substantive evidence to support the clinical utility of family histories. Annual collection of a comprehensive 3-generation family history has been held up as the gold standard for practice. However, interval family histories targeted to symptoms and family histories tailored to a child’s life stage (ie, age-based health) may be important and underappreciated methods of collecting family history that yield clinically actionable data and supplement existing family history information. In this article, we review the various applications, as well as capabilities and limitations, of the family history for primary care providers. PMID:24298128
Tarini, Beth A; McInerney, Joseph D
The family history has been called the first genetic test; it was a core element of primary care long before the current wave of genetics technologies and services became clinically relevant. Risk assessment based on family history allows providers to personalize and prioritize health messages, shifts the focus of health care from treatment to prevention, and can empower individuals and families to be stewards of their own health. In a world of rising health care costs, the family history is an important tool, with its primary cost being the clinician's time. However, a recent National Institutes of Health conference highlighted the lack of substantive evidence to support the clinical utility of family histories. Annual collection of a comprehensive 3-generation family history has been held up as the gold standard for practice. However, interval family histories targeted to symptoms and family histories tailored to a child's life stage (ie, age-based health) may be important and underappreciated methods of collecting family history that yield clinically actionable data and supplement existing family history information. In this article, we review the various applications, as well as capabilities and limitations, of the family history for primary care providers.
Federman, Alex D; Cook, E Francis; Phillips, Russell S; Puopolo, Ann Louise; Haas, Jennifer S; Brennan, Troyen A; Burstin, Helen R
BACKGROUND Specific elements of health care process and physician behavior have been shown to influence disenrollment decisions in HMOs, but not in outpatient settings caring for patients with diverse types of insurance coverage. OBJECTIVE To examine whether physician behavior and process of care affect patients' intention to return to their usual health care practice. DESIGN Cross-sectional patient survey and medical record review. SETTING Eleven academically affiliated primary care medicine practices in the Boston area. PATIENTS 2,782 patients with at least one visit in the preceding year. MEASUREMENT Unwillingness to return to the usual health care practice. RESULTS Of the 2,782 patients interviewed, 160 (5.8%) indicated they would not be willing to return. Two variables correlated significantly with unwillingness to return after adjustment for demographics, health status, health care utilization, satisfaction with physician's technical skill, site of care, and clustering of patients by provider: dissatisfaction with visit duration (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4 to 7.4) and patient reports that the physician did not listen to what the patient had to say (OR, 8.8; 95% CI, 2.5 to 30.7). In subgroup analysis, patients who were prescribed medications at their last visit but who did not receive an explanation of the purpose of the medication were more likely to be unwilling to return (OR, 4.9; 95% CI, 1.8 to 13.3). CONCLUSION Failure of physicians to acknowledge patient concerns, provide explanations of care, and spend sufficient time with patients may contribute to patients' decisions to discontinue care at their usual site of care. PMID:11679034
Rogan, Lisa; Boaden, Ruth
Purpose Principal-agent theory (PAT) has been used to understand relationships among different professional groups and explain performance management between organisations, but is rarely used for research within primary care. The purpose of this paper is to explore whether PAT can be used to attain a better understanding of performance management in primary care. Design/methodology/approach Purposive sampling was used to identify a range of general practices in the North-west of England. Interviews were carried out with directors, managers and clinicians in commissioning and regional performance management organisations and within general practices, and the data analysed using matrix analysis techniques to produce a case study of performance management. Findings There are various elements of the principal-agent framework that can be applied in primary care. Goal alignment is relevant, but can only be achieved through clear, strategic direction and consistent interpretation of objectives at all levels. There is confusion between performance measurement and performance management and a tendency to focus on things that are easy to measure whilst omitting aspects of care that are more difficult to capture. Appropriate use of incentives, good communication, clinical engagement, ownership and trust affect the degree to which information asymmetry is overcome and goal alignment achieved. Achieving the right balance between accountability and clinical autonomy is important to ensure governance and financial balance without stifling innovation. Originality/value The principal-agent theoretical framework can be used to attain a better understanding of performance management in primary care; although it is likely that only partial goal alignment will be achieved, dependent on the extent and level of alignment of a range of factors.
Westfall, Matthew Y; Overholser, Linda; Zittleman, Linda; Westfall, John M
Long-term cancer survivorship care is a relatively new and rapidly advancing field of research. Increasing cancer survivorship rates have created a huge population of long-term cancer survivors whose cancer-specific needs challenge healthcare infrastructure and highlight a significant deficit of knowledge and guidelines in transitional care from treatment to normalcy/prolonged survivorship. As the paradigm of cancer care has changed from a fixation on the curative to the maintenance on long-term overall quality of life, so to, has the delineation of responsibility between oncologists and primary care physicians (PCPs). As more patients enjoy long-term survival, PCPs play a more comprehensive role in cancer care following acute treatment. To this end, this annotated bibliography was written to provide PCPs and other readers with an up-to-date and robust base of knowledge on long-term cancer survivorship, including definitions and epidemiological information as well as specific considerations and recommendations on physical, psychosocial, sexual, and comorbidity needs of survivors. Additionally, significant information is included on survivorship care, specifically Survivorship Care Plans (SPCs) and their evolution, utilization by oncologists and PCPs, and current gaps, as well as an introduction to patient navigation programs. Given rapid advancements in cancer research, this bibliography is meant to serve as current baseline reference outlining the state of the science.
Jessen, Frank; Wiese, Birgitt; Bickel, Horst; Eiffländer-Gorfer, Sandra; Fuchs, Angela; Kaduszkiewicz, Hanna; Köhler, Mirjam; Luck, Tobias; Mösch, Edelgard; Pentzek, Michael; Riedel-Heller, Steffi G.; Wagner, Michael; Weyerer, Siegfried; Maier, Wolfgang; van den Bussche, Hendrik
Background Current approaches for AD prediction are based on biomarkers, which are however of restricted availability in primary care. AD prediction tools for primary care are therefore needed. We present a prediction score based on information that can be obtained in the primary care setting. Methodology/Principal Findings We performed a longitudinal cohort study in 3.055 non-demented individuals above 75 years recruited via primary care chart registries (Study on Aging, Cognition and Dementia, AgeCoDe). After the baseline investigation we performed three follow-up investigations at 18 months intervals with incident dementia as the primary outcome. The best set of predictors was extracted from the baseline variables in one randomly selected half of the sample. This set included age, subjective memory impairment, performance on delayed verbal recall and verbal fluency, on the Mini-Mental-State-Examination, and on an instrumental activities of daily living scale. These variables were aggregated to a prediction score, which achieved a prediction accuracy of 0.84 for AD. The score was applied to the second half of the sample (test cohort). Here, the prediction accuracy was 0.79. With a cut-off of at least 80% sensitivity in the first cohort, 79.6% sensitivity, 66.4% specificity, 14.7% positive predictive value (PPV) and 97.8% negative predictive value of (NPV) for AD were achieved in the test cohort. At a cut-off for a high risk population (5% of individuals with the highest risk score in the first cohort) the PPV for AD was 39.1% (52% for any dementia) in the test cohort. Conclusions The prediction score has useful prediction accuracy. It can define individuals (1) sensitively for low cost-low risk interventions, or (2) more specific and with increased PPV for measures of prevention with greater costs or risks. As it is independent of technical aids, it may be used within large scale prevention programs. PMID:21364746
Deligiannidis, Konstantinos E
Rural populations have different demographics and health issues compared to their metropolitan counterparts, including higher mortalities from ischemic heart disease, chronic obstructive pulmonary disease, unintentional injuries, motor vehicle accidents, and suicide. Rural primary care physicians (PCPs) have a unique position in counseling, preventing, and treating common issues that are specific to rural populations, such as motor vehicle accidents, unintentional injuries, pesticide poisoning, occupational respiratory illnesses, and mental illness. They are also in a unique position to address prevention and social determinants of health. Rural PCPs can use multiple strategies to improve access to medical care.
This paper explores the entrepreneurial role of dentists in primary care dentistry. It reviews the changing context of dentistry, not least the reforms being introduced by the health and social care bill. It suggests that this new context will reinforce the need to consider the business side of dental practice, in particular, the importance of quality, creativity and innovation, alongside the importance of meeting the needs of patients. An entrepreneurial approach will be required in order to sustain dental practice in an increasingly competitive environment.
Cox, Kim J; King, Tekoa L
The incidence of cesarean birth in the United States is alarmingly high and cesareans are associated with added morbidities for women and newborns. Thus strategies to prevent cesarean particularly for low-risk, nulliparous women at term with a singleton fetus are needed. This article addresses evidence-based practices that may be used during intrapartum to avoid primary cesarean, including patience with progress in labor, intermittent auscultation, continuous labor support, upright positions, and free mobility. Second-stage labor practices, such delayed pushing and manual rotation of the fetus, are also reviewed. This package of midwifery-style care practices can potentially lower primary cesarean rates.
... 42 Public Health 4 2011-10-01 2011-10-01 false Primary care case management services. 440.168... care case management services. (a) Primary care case management services means case management related... services. (b) Primary care case management services may be offered by the State— (1) As a voluntary...
... 42 Public Health 4 2012-10-01 2012-10-01 false Primary care case management services. 440.168... care case management services. (a) Primary care case management services means case management related... services. (b) Primary care case management services may be offered by the State— (1) As a voluntary...
... 42 Public Health 4 2014-10-01 2014-10-01 false Primary care case management services. 440.168... care case management services. (a) Primary care case management services means case management related... services. (b) Primary care case management services may be offered by the State— (1) As a voluntary...
... 42 Public Health 4 2013-10-01 2013-10-01 false Primary care case management services. 440.168... care case management services. (a) Primary care case management services means case management related... services. (b) Primary care case management services may be offered by the State— (1) As a voluntary...
Fisher, Elisa; Hasselberg, Michael; Conwell, Yeates; Weiss, Linda; Padrón, Norma A; Tiernan, Erin; Karuza, Jurgis; Donath, Jeremy; Pagán, José A
Health care delivery and payment systems are moving rapidly toward value-based care. To be successful in this new environment, providers must consistently deliver high-quality, evidence-based, and coordinated care to patients. This study assesses whether Project ECHO(®) (Extension for Community Healthcare Outcomes) GEMH (geriatric mental health)-a remote learning and mentoring program-is an effective strategy to address geriatric mental health challenges in rural and underserved communities. Thirty-three teleECHO clinic sessions connecting a team of specialists to 54 primary care and case management spoke sites (approximately 154 participants) were conducted in 10 New York counties from late 2014 to early 2016. The curriculum consisted of case presentations and didactic lessons on best practices related to geriatric mental health care. Twenty-six interviews with program participants were conducted to explore changes in geriatric mental health care knowledge and treatment practices. Health insurance claims data were analyzed to assess changes in health care utilization and costs before and after program implementation. Findings from interviews suggest that the program led to improvements in clinician geriatric mental health care knowledge and treatment practices. Claims data analysis suggests that emergency room costs decreased for patients with mental health diagnoses. Patients without a mental health diagnosis had more outpatient visits and higher prescription and outpatient costs. Telementoring programs such as Project ECHO GEMH may effectively build the capacity of frontline clinicians to deliver high-quality, evidence-based care to older adults with mental health conditions and may contribute to the transformation of health care delivery systems from volume to value.
Alavosius, M P; Sulzer-Azaroff, B
Two schedules of feedback were examined to determine their relative effects on the acquisition and maintenance of three health-care routines: feeding, positioning, and transferring physically disabled patients. Four direct service providers' performances in the natural environment were measured weekly. Concurrent schedules and multiple baselines across subjects and response classes were used to evaluate the effects of written instructions combined with either continuous, intermittent, or nofeedback schedules. Results showed that instructions alone led to slight and usually brief changes. Marked improvements were noted after feedback was introduced, with the continuous schedule producing more rapid acquisition. Follow-up measures indicated performance maintenance for both schedules. Subjects rated the feedback programs favorably and recommended provision of this service to co-workers. Cost estimates indicated that, although considerable time was spent developing the observational system, the feedback procedure was relatively inexpensive, easy to use, and did not interfere with patient care. PMID:2373652
Griffiths, F; Wild, A; Harvey, J; Fenton, E
Primary care research networks are being publicly funded in the United Kingdom to promote a culture of research and development in primary care. This paper discusses the organisational form of these networks and how their productivity can be evaluated, drawing on evidence from management science. An evaluation of a research network has to take account of the complexity of the organisation, the influence of its local context, and its stage of development. Output measures, such as number of research papers, and process measures, such as number of research meetings, may contribute to an evaluation. However, as networking relies on the development of informal, trust-based relationships, the quality of interactions within a network is of paramount importance for its success. Networks can audit and reflect on their success in promoting such relationships and a more formal qualitative evaluation by an independent observer can document their success to those responsible for funding. PMID:11141879
Fleming, Sara A.; Gutknecht, Nancy C.
Synopsis Naturopathy is a distinct type of primary care medicine that blends age-old healing traditions with scientific advances and current research. It is guided by a unique set of principles that recognize the body's innate healing capacity, emphasize disease prevention, and encourage individual responsibility to obtain optimal health. Naturopathic treatment modalities include diet and clinical nutrition, behavioral change, hydrotherapy, homeopathy, botanical medicine, physical medicine, pharmaceuticals, and minor surgery. Naturopathic physicians (NDs) are trained as primary care physicians in four-year, accredited doctoral-level naturopathic medical schools. Currently, there are 15 U.S. states, 2 U.S. territories, and a number of provinces in Canada, Australia, and New Zealand that recognize licensure for NDs. PMID:20189002
Smith, Emily; Narang, Puneet; Enja, Manasa; Lippmann, Steven
Pharmacotherapy for insomnia in primary care settings can be challenging. Frequently, there are multiple coexisting medical and psychiatric conditions, drug interactions, concern regarding use of habit-forming sleep aids, and paucity of time in office visits to discuss management of sleep difficulties. This article reports the results of a literature search related to pharmacotherapy for insomnia and presents 4 clinical vignettes with corresponding treatment options. PMID:27486547
Lee, Linda; Patel, Tejal; Costa, Andrew; Bryce, Erin; Hillier, Loretta M.; Slonim, Karen; Hunter, Susan W.; Heckman, George; Molnar, Frank
Abstract Objective To examine the accuracy of individual Fried frailty phenotype measures in identifying the Fried frailty phenotype in primary care. Design Retrospective chart review. Setting A community-based primary care practice in Kitchener, Ont. Participants A total of 516 patients 75 years of age and older who underwent frailty screening. Main outcome measures Using modified Fried frailty phenotype measures, frailty criteria included gait speed, hand-grip strength as measured by a dynamometer, and self-reported exhaustion, low physical activity, and unintended weight loss. Sensitivity, specificity, accuracy, and precision were calculated for single-trait and dual-trait markers. Results Complete frailty screening data were available for 383 patients. The overall prevalence of frailty based on the presence of 3 or more frailty criteria was 6.5%. The overall prevalence of individual Fried frailty phenotype markers ranged from 2.1% to 19.6%. The individual criteria all showed sensitivity and specificity of more than 80%, with the exception of weight loss (8.3% and 97.4%, respectively). The positive predictive value of the single-item criteria in predicting the Fried frailty phenotype ranged from 12.5% to 52.5%. When gait speed and hand-grip strength were combined as a dual measure, the positive predictive value increased to 87.5%. Conclusion There is a need for frailty measures that are psychometrically sound and feasible to administer in primary care. While use of gait speed or grip strength alone was found to be sensitive and specific as a proxy for the Fried frailty phenotype, use of both measures together was found to be accurate, precise, specific, and more sensitive than other possible combinations. Assessing both measures is feasible within primary care. PMID:28115460
Eshet, I; Van Relta, R; Margalit, A; Baharir, Z
This department of family medicine has been challenged with helping a group of Russian immigrant physicians find places in primary care clinics, quickly and at minimal expense. A 3-month course was set up based on the Family Practice Residency Syllabus and the SFATAM approach, led by teachers and tutors from our department. 30 newly immigrated Russian physicians participated. The course included: lectures and exercises in treatment and communication with patients with a variety of common medical problems in the primary care setting; improvement of fluency in Hebrew relevant to the work setting; and information on the function of primary care and professional clinics. Before-and-after questionnaires evaluating optimal use of a 10- minute meeting with a client presenting with headache were administered. The data showed that the physicians had learned to use more psychosocial diagnostic question and more psychosocial interventions. There was a cleared trend toward greater awareness of the patient's environment, his family, social connections and work. There was no change in biomedical inquiry and interventions but a clear trend to a decrease in recommendations for tests and in referrals. The authors recommend the following didactic tools: adopting a biopsychosocial attitude, active participation of students in the learning situation, working in small groups, use of simulations and video clips, and acquiring basic communication experience.
Lane, Christianne J.; Williams, Marian E.; Dawson, Michael E.; Polido, José C.; Cermak, Sharon A.
Background. Children with autism spectrum disorders (ASD) commonly exhibit uncooperative behaviors which impede oral care. Previous studies have utilized dentist-report measures of uncooperative behaviors in children with ASD but none have utilized an objective measure of children's behavior or a physiological measure of distress. This study investigated behavioral and physiological distress in children with ASD during routine oral care and examined factors associated with this distress. Methods. Participants were 44 children (n = 22 typical, n = 22 ASD) aged 6–12 receiving routine dental cleanings. Behavioral and physiological measures of stress and anxiety were collected during dental cleanings. Results. Children with ASD exhibited greater distress, compared to the typical group, on dentist-report and researcher-coded measures of overt distress behaviors and on physiological measures. Correlations between physiological and behavioral measures of distress were found in the ASD but not in the typical group. Behavioral distress was correlated with age in the typical group and with expressive communication ability and sensory processing difficulties in the ASD group; physiological distress was correlated with parent-report of anxiety in the typical group and sensory processing difficulties in the ASD group. Conclusions. Novel strategies may be required to decrease behavioral and physiological distress in children with ASD in the dental clinic. PMID:25114916
Beaulieu, Marie-Dominique; Geneau, Robert; Grande, Claudio Del; Denis, Jean-Louis; Hudon, Éveline; Haggerty, Jeannie L.; Bonin, Lucie; Duplain, Réjean; Goudreau, Johanne; Hogg, William
Abstract Objective To gain a deeper understanding of how primary care (PC) practices belonging to different models manage resources to provide high-quality care. Design Multiple-case study embedded in a cross-sectional study of a random sample of 37 practices. Setting Three regions of Quebec. Participants Health care professionals and staff of 5 PC practices. Methods Five cases showing above-average results on quality-of-care indicators were purposefully selected to contrast on region, practice size, and PC model. Data were collected using an organizational questionnaire; the Team Climate Inventory, which was completed by health care professionals and staff; and 33 individual interviews. Detailed case histories were written and thematic analysis was performed. Main findings The core common feature of these practices was their ongoing effort to make trade-offs to deliver services that met their vision of high-quality care. These compromises involved the same 3 areas, but to varying degrees depending on clinic characteristics: developing a shared vision of high-quality care; aligning resource use with that vision; and balancing professional aspirations and population needs. The leadership of the physician lead was crucial. The external environment was perceived as a source of pressure and dilemmas rather than as a source of support in these matters. Conclusion Irrespective of their models, PC practices’ pursuit of high-quality care is based on a vision in which accessibility is a key component, balanced by appropriate management of available resources and of external environment expectations. Current PC reforms often create tensions rather than support PC practices in their pursuit of high-quality care. PMID:24829023
Taliaferro, Lindsay A.; Muehlenkamp, Jennifer J.; Hetler, Joel; Edwall, Glenace; Wright, Catherine; Edwards, Anne; Borowsky, Iris W.
Primary care providers were surveyed to determine how prepared they feel to address nonsuicidal self-injury (NSSI) among adolescents, their interest in training on NSSI, and factors associated with routinely asking about NSSI when providing health supervision. Participants included family medicine physicians ("n" = 260), pediatricians…
Hayeems, Robin Z.; Miller, Fiona A.; Carroll, June C.; Little, Julian; Allanson, Judith; Bytautas, Jessica P.; Chakraborty, Pranesh; Wilson, Brenda J.
Abstract Objective To examine the role of primary care providers in informing and supporting families who receive positive screening results. Design Cross-sectional survey. Setting Ontario. Participants Family physicians, pediatricians, and midwives involved in newborn care. Main outcome measures Beliefs, practices, and barriers related to providing information to families who receive positive screening results for their newborns. Results A total of 819 providers participated (adjusted response rate of 60.9%). Of the respondents, 67.4% to 81.0% agreed that it was their responsibility to provide care to families of newborns who received positive screening results, and 64.2% to 84.8% agreed they should provide brochures or engage in general discussions about the identified conditions. Of the pediatricians, 67.3% endorsed having detailed discussions with families, but only 24.1% of family physicians and 27.6% of midwives endorsed this practice. All provider groups reported less involvement in information provision than they believed they should have. This discrepancy was most evident for family physicians: most stated that they should provide brochures (64.2%) or engage in general discussions (73.5%), but only a minority did so (15.3% and 27.7%, respectively). Family physicians reported insufficient time (42.2%), compensation (52.2%), and training (72.3%) to play this role, and only a minority agreed they were up to date (18.5%) or confident (16.5%) regarding newborn screening. Conclusion Providers of primary newborn care see an information-provision role for themselves in caring for families who receive positive newborn screening results. Efforts to further define the scope of this role combined with efforts to mitigate existing barriers are warranted. PMID:23946032
de Souza, Marina Celly Martins Ribeiro; Freitas, Maria Imaculada de Fátima
This was a qualitative study, based on the Social Representations Theory, with professionals that work in primary care, about the risk of HIV infection to which they are exposed in their quotidian work routine. Twelve physicians and nurses who work in two Health Centers in the city of Belo Horizonte, MG, Brazil, were interviewed. The final analysis, carried out using the saturation of information criterion, was based on the method proposed by Structural Analysis of Narrative. The results show that the health professionals interviewed knew the infection risk in their work routine, representing it as very low in primary care, because they relate it to technological complexity which they consider does not exist in the level of assistance in which they work. They believed that the use of personal protection equipment may minimize the risks and that, nowadays, no primary care professional refuses to attend a patient due to fear of infection, even if not using all the recommended precautions.
McNaughton, Jennifer L.
Abstract OBJECTIVE To assess existing, brief nonpharmacologic interventions that are available for primary care physicians with minimal training in psychotherapy to use in managing depression in adult patients. DATA SOURCES MEDLINE was searched from 1996 to 2007, EMBASE was searched from 1980 to 2007, and EBM Reviews was searched from 1999 to 2007. STUDY SELECTION Several randomized controlled trials were selected using specified criteria. Selected articles were subsequently appraised and qualitatively analyzed. SYNTHESIS Significant improvements on depression scales were found in 6 out of 8 studies (P < .05) using various brief interventions and formal control groups. Successful interventions included bibliotherapy, websites based on cognitive-behavioural therapy (CBT), and CBT-based computer programs. Completion rates were highest when interventions were shorter, more structured, and included frequent contact or reminders from study staff. Validity limitations included small sample sizes, non-blinding of studies, and an uncertain degree of generalizability. CONCLUSION Bibliotherapy, CBT-based websites, and CBT-based computer programs might be effective in assisting primary care physicians who have minimal training in psychotherapy in treating adult patients with depression. Health care personnel contact with patients undergoing these interventions might result in increased effectiveness. Future research is warranted in this area, and despite several limitations, findings from this study could help guide efforts in the development and evaluation of such research. PMID:19675262
In the UK public service organisations are increasingly working together in new partnerships, networks and alliances, largely stimulated by government legislation, which aims to encourage 'joined-up' policy-making. This is particularly prevalent in health-care where local government, health authorities and trusts, voluntary and community groups are extending existing, and developing new, forms of partnership, particularly around Health Improvement Programmes and new primary care organisations. This paper explores two main aspects of how these new interorganizational relationships are being developed and managed and is based on research conducted in one case study locality. First, the new structures of partnership in primary care are mapped out, together with discussion on why these particular patterns of relationship between statutory and voluntary sector organisations have emerged, exploring both centrally and locally determined influences. Secondly, the paper explores the tensions associated with working within new policy-making and management structures, and how the additional demands of audit, performance measurement and the sheer pace of change, pose a potential threat to the partnership process.
Bulik, Robert J
Traditional delivery of primary care takes place in a face-to-face transaction between provider and patient. In telemedicine, however, the transaction is 'filtered' by the distance and technology. The potential problem of filtered communication in a telemedicine encounter was examined from a human factors perspective. Patients with and without experience of telemedicine, and providers who had experience of telemedicine, were asked about patient-provider relationships in interviews and focus groups. Seven themes emerged: initial impressions, style of questions, field of view, physical interaction, social talk, control of encounter and ancillary services. This suggests that communication can be improved and better patient-provider relationships can be developed in a primary care telemedicine encounter if attention is paid to four areas of the interaction: verbal, non-verbal, relational and actions/transactional. The human factors dimension of telemedicine is an important element in delivery of health care at a distance - and is one of few factors over which the provider has direct control.
Kastner, Theodore A.; Walsh, Kevin K.
Lack of sufficient accessible community-based health care services for individuals with developmental disabilities has led to disparities in health outcomes and an overreliance on expensive models of care delivered in hospitals and other safety net or state-subsidized providers. A functioning community-based primary health care model, with an…
The CPN seeks to enhance the care of patients by judicious expenditure of health care dollars, currently for the Unit "Community" Network, but ultimately also for other insurers who would enter risk-sharing relationships with the CPN. Improvements in health care delivery will be made in enhanced access to primary care, including telephone access to nurse triage; in collaboration and communication between the selected consultant and the referring primary care giver, including an electronic network allowing for selected information sharing; and in renewing medicine's collective commitment to care provided as close to home as possible, or in the home if this is the highest quality. The care of the uninsured remains a challenge and a normal obligation from which the CPN does not shrink. The economic realities of primary care delivery must be improved, with additional resources allocated being substantially rededicated to patient care. The patient's control of the selection of the site of health care and the absence of incentives to their primary care provider for a referral pattern different than the patient's choice will remain important to the CPN. The CPN hopes to provide the diplomacy between third party payers to enhance collaboration and minimize competition in the delivery of care in communities.
Eksi, F; Mehli, M; Akgun, S; Bayram, A; Balci, I; Aydin, N
In this study, the antimicrobial efficacy of hand washing (HW) and hand washing plus rubbing with an alcohol-based solution (HWR) on numbers of total and transient flora colonies on the hands of healthcare workers (HCWs) during routine patient care was assessed. Samples were collected, using a standard bag broth technique, from the hands of 154 HCWs, before and immediately after carrying out a hand hygiene procedure. The numbers of total and transient flora colonies per plate were counted and transient pathogens were identified. A significant statistical difference between ward speciality was detected with respect to the isolation rate of transient flora. Transient hand flora were recovered from 25.3% of HCWs before carrying out the hand hygiene procedure. With respect to the disappearance and prevention of regrowth of transient flora after hand hygiene, the HWR technique was significantly more effective than HW. In conclusion, a disinfectant should be added to the hand washing process to achieve optimum protection against nosocomial infections in routine hospital practice.
Myrianthefs, Pavlos; Evodia, Efimia; Vlachou, Ioanna; Petrocheilou, Glykeria; Gavala, Alexandra; Pappa, Maria; Baltopoulos, George; Karakitsos, Dimitrios
Objective. We evaluated whether routine ultrasound examination may illustrate gallbladder abnormalities, including acute acalculous cholecystitis (AAC) in the intensive care unit (ICU). Patients and Methods. Ultrasound monitoring of the GB was performed by two blinded radiologists in mechanically ventilated patients irrespective of clinical and laboratory findings. We evaluated major (gallbladder wall thickening and edema, sonographic Murphy's sign, pericholecystic fluid) and minor (gallbladder distention and sludge) ultrasound criteria. Measurements and Results. We included 53 patients (42 males; mean age 57.6 ± 2.8 years; APACHE II score 21.3 ± 0.9; mean ICU stay 35.9 ± 4.8 days). Twenty-five patients (47.2%) exhibited at least one abnormal imaging finding, while only six out of them had hepatic dysfunction. No correlation existed between liver biochemistry and ultrasound results in the total population. Three male patients (5.7%), on the grounds of unexplained sepsis, were diagnosed with AAC as incited by ultrasound, and surgical intervention was lifesaving. Patients who exhibited ≥2 ultrasound findings (30.2%) were managed successfully under the guidance of evolving ultrasound, clinical, and laboratory findings. Conclusions. Ultrasound gallbladder monitoring guided lifesaving surgical treatment in 3 cases of AAC; however, its routine application is questionable and still entails high levels of clinical suspicion.
Background The majority of young children receive no early dental examination while attending primary health care for routine check-ups. Our aim was to study primary care nurses’ knowledge of oral health care (OHC) and their attitudes toward delivering OHC, as well as to assess their willingness to obtain OHC information. Methods We conducted a cross-sectional survey of all primary-care nurses working in the public health centres of Tehran city. An anonymous self-administered questionnaire queried their knowledge in paediatric-, general and medicine-related areas of dentistry, providing knowledge scores for three domains. The nurses’ attitudes toward OHC and their willingness to obtain OHC information underwent evaluation with statements utilizing a five-point Likert scale. Altogether 680 nurses took part in the survey. The Chi-square test, t-test, one-way ANOVA and logistic regression model served for statistical analyses. Result The mean score for the paediatric dentistry domain (3.6, SD: 1.5) was lower than for the medical (4.4, SD: 2.3) and dental domains (5.8, SD: 1.5). Obtaining higher scores in the paediatric (OR = 1.2) and dental (OR = 1.3) domains, and a greater willingness to receive OHC information (OR = 5.3), were associated with a positive attitude toward OHC. Nurses with a lower education (OR = 1.9) and better oral health behaviour (OR = 1.1) as well as those working in a non-affluent region (OR = 1.6) had a more positive attitude toward OHC. Conclusion Primary care nurses’ low level of knowledge in OHC and their positive attitude and willingness to obtain more information point to the need for appropriate OHC training and encouragement for the nurses to promote oral health and prevent dental diseases. PMID:24670004
Piccinini-Vallis, Helena; Lee-Baggley, Dayna; Stewart, Moira; Ryan, Bridget
Objective To identify gestational weight gain trajectories, stratified by prepregnancy body mass index (BMI), of women with singleton pregnancies who received prenatal care in a primary care setting, and to compare these trajectories with the 2009 Institute of Medicine gestational weight gain recommendations. Design Retrospective cohort study. Setting Halifax, NS. Participants Women who received prenatal care at the Dalhousie Family Medicine clinics in Halifax from 2009 to 2013. Main outcome measures For each prenatal visit, gestational age and weight measurements were obtained. Multilevel modeling was used to analyze the gestational weight gain trajectories. The upper limit of the guideline-recommended weekly gestational weight gain was compared with the 95% CI of the observed mean weekly gestational weight gain for each prepregnancy BMI category. Results A total of 280 women were included in the analyses. There was a significant interaction between prepregnancy BMI category and gestational weight gain over time (P < .001), with gestational weight gain being significantly lower among women with prepregnancy BMI of 30.0 kg/m2 or greater compared with those with BMI of 18.5 to less than 25.0 kg/m2 and 25.0 to less than 30.0 kg/m2. When comparing women’s weight gain with the recommendations, women with prepregnancy BMI of 25.0 to less than 30.0 kg/m2 had the most guideline discordance, deviating from the weight gain recommendations at 20 weeks’ gestation. Conclusion These results are relevant and of benefit to women and clinicians wishing to address excess gestational weight gain, and to researchers and policy makers developing interventions aimed at curbing gestational weight gain in primary care. Although our results showed women with prepregnancy BMI of 25.0 to less than 30.0 kg/m2 gained the most excess, guideline-discordant weight, interventions should target all women planning or experiencing a pregnancy.
There is growing consensus that treatment of cardiovascular risks should be based on multiple rather than single factors and on absolute rather than relative risks. Thresholds for treatment should reflect the level of absolute risk at which the benefits and hazards of treating outweigh the benefits and hazards of not treating. Once a decision has been made to initiate a treatment programme, clinicians need to know the patient's absolute risk. At this level of risk do the benefits of treatment outweigh the hazards? Given this information, which treatment option does the patient prefer? Using cardiovascular disease as an example, I review some measures that assist decision making in primary care. Practice guidelines should routinely include accessible presentation of treatment outcomes on benefit, hazard, and costs for a range of absolute risks. These measures enable patients and their doctors to weigh the pros and cons of treatment in their particular circumstances. PMID:9022493
Comer, Dominique; Mearns, Elizabeth; Olivere, Lindsey; Elliott, Daniel J
Improvements in health information technology have made aggregate multipayer pharmacy claims data increasingly available through the electronic health record (EHR). The objective of this study was to assess the current awareness, utilization, and impact of pharmacy history data available in the EHR on primary care provider (PCP) decision making. A 14-question survey was distributed to all PCPs in a large medical practice. Of the 55/72 responding PCPs, 47 (85.5%) were aware of the EHR medication history function, and 36 (65.5%) had used it previously. Respondents indicated the medication history could be most useful when considering prescribing a narcotic (33/36, 92%) and when addressing nonadherence concerns (28/35, 80%). Barriers included delays in data loading and the time pressures of clinical practice. Access to aggregate multipayer pharmacy history data has the potential to affect medication reconciliation, yet future implementation should focus on making these data complete and easily available in routine practice.
García-Martínez, F J; Pascual, J C; López-Martín, I; Pereyra-Rodríguez, J J; Martorell Calatayud, A; Salgado-Boquete, L; Labandeira-García, J
Hidradenitis suppurativa is a prevalent disease that is noted for its clinical variability and by its severe impact on quality of life. A meticulous scientific literature review is presented in this article in order to give an update on what is known on this condition. Primary Care physicians obviously play an important role in the early diagnosis and management of hidradenitis suppurativa. This review aims to provide a current and practical overview about this disease in order to optimise the healthcare for these patients by making the best use of available resources.
Leung, Marcia A; Flaherty, Anna; Zhang, Julia A; Hara, Jared; Barber, Wayne
The primary care physician's role in recognizing sudden sensorineural hearing (SSNHL) loss and delivering initial treatment is critical in the management of the syndrome. This role involves recognizing its clinical symptoms, distinguishing it from conductive hearing loss with the Weber tuning fork or the Rauch hum test, and urgent administration of high dose oral corticosteroids. Diagnosis and treatment should not be delayed for audiometric testing or referral to otolaryngology. This paper provides an update on the initial evaluation and treatment of this syndrome based on the literature and clinical guideline recommendations. PMID:27413627
Bentsen, Bent Guttorm
In ordinary general practice, and in medical research, the problems encountered must be labelled. The Characteristics and classification of the labels used are discussed in this paper. Some different classification systems are discussed including that of the Royal College of General Practitioners. The need for one international classification system is stressed. The World Organisation of National Colleges and Academies of General Practice (WONCA) has now approved an International Classification of Health Problems in Primary Care, which was accepted by all countries during the sixth World Conference on General Practice in November 1974. PMID:1053266
Abstract This is the second article in the series on African primary care research. The article focuses on how to search for relevant evidence in the published literature that can be used in the development of a research proposal. The article addresses the style of writing required and the nature of the arguments for the social and scientific value of the proposed study, as well as the use of literature in conceptual frameworks and in the methods. Finally, the article looks at how to keep track of the literature used and to reference it appropriately. PMID:26245433
Scherer, Magda Duarte dos Anjos; de Pires, Denise Elvira Pires; Jean, Rémy
Interdisciplinarity in the work routine of professionals of a Residency Course on Family Health in Southern Brazil was investigated in a qualitative study involving 11 residents and 5 supervisors of seven professions. Through interviews, observations and focal groups the existence of interdisciplinarity in practice was analyzed, duly identifying favorable and unfavorable aspects for its implementation. Interdisciplinarity was expressed as a complex process and concrete action, which occurs in the dramatic implications of its usage, in a dialectical relationship with the political and institutional context. The study revealed that working in family health care renders the work more complex and that the professionals experience difficulties in sharing knowledge and making the transition between multidisciplinarity and interdisciplinarity. The study concludes that interdisciplinarity requires the integrated use of knowledge in the multi-professional practice, the crossing of disciplinary boundaries, the development of competencies to address the challenges of the work environment and personal attitude as a basic component for professional action.
Background Evidence-based quality improvement models for depression have not been fully implemented in routine primary care settings. To date, few studies have examined the organizational factors associated with depression management in real-world primary care practice. To successfully implement quality improvement models for depression, there must be a better understanding of the relevant organizational structure and processes of the primary care setting. The objective of this study is to describe these organizational features of routine primary care practice, and the organization of depression care, using survey questions derived from an evidence-based framework. Methods We used this framework to implement a survey of 27 practices comprised of 49 unique offices within a large primary care practice network in western Pennsylvania. Survey questions addressed practice structure (e.g., human resources, leadership, information technology (IT) infrastructure, and external incentives) and process features (e.g., staff performance, degree of integrated depression care, and IT performance). Results The results of our survey demonstrated substantial variation across the practice network of organizational factors pertinent to implementation of evidence-based depression management. Notably, quality improvement capability and IT infrastructure were widespread, but specific application to depression care differed between practices, as did coordination and communication tasks surrounding depression treatment. Conclusions The primary care practices in the network that we surveyed are at differing stages in their organization and implementation of evidence-based depression management. Practical surveys such as this may serve to better direct implementation of these quality improvement strategies for depression by improving understanding of the organizational barriers and facilitators that exist within both practices and practice networks. In addition, survey information can
Sparks, Toni; Kawi, Jennifer; Menzel, Nancy Nivison; Hartley, Kendall
Fibromyalgia management remains complicated and challenging. Health information technology is an evidence-based, nonpharmacological self and symptom management strategy, but few studies have evaluated its feasibility for managing fibromyalgia patients in clinical practice. FibroGuide is an example of an evidence-based, interactive, and computer-based program comprised of 10 educational modules on fibromyalgia. Study aims were to: (1) develop a process for implementing FibroGuide into the routine care of patients with fibromyalgia, (2) evaluate the overall impact on fibromyalgia before and after a 12-week implementation, and (3) assess patient perspectives on using FibroGuide health information technology to assist in self-management. In this pilot study, 35 participants with fibromyalgia were recruited from an Advanced Practice Registered Nurse's outpatient clinic. Using a descriptive design, quantitative data analysis was employed to address study aims. Based on data collection pre- and post-intervention using paired samples testing, a statistically significant change (p = .017) was observed in overall fibromyalgia impact (improved symptom severity, activity, and function). Majority felt that FibroGuide was helpful as part of their routine care, and nearly half reported that it assisted in their self-management. Although 65% noted that technology was an effective and efficient way to receive education for fibromyalgia management, 57% preferred talking to healthcare providers. Larger longitudinal studies are needed on the use of health information technology in fibromyalgia, evaluating both statistical and clinical significance, while decreasing barriers to participant use for this promising adjunct to clinical management. Providers need to be well educated on supporting self-management strategies and health information technology.
Keglević, Mladenka Vrcić; Kovačić, Luka; Pavleković, Gordana
It is well known that countries with strong primary care achieve better health outcomes at lower costs. Therefore, the effort of World Health Organization in promoting primary care as a basic principal of successful health care system is an ongoing process. Although Croatia was recognized as a country with primary care orientation due to the development of health centers and introduction of specialist training of general practitioners, it seems that many health care reforms aimed at better organization of health institutions and decreasing of health care costs did not result with higher primary care orientation. By application of the Primary Care Score instrument in 2014 (Croatia received 11.2 out of 20 possible points), and international comparison performed in 2002, it was concluded that among the eighteen OECD countries Croatia could be categorized as an "intermediate primary care country", obtaining the scores just a bit above the average.
Neves, Matheus; Giordani, Jessye Melgarejo do Amaral; Ferla, Alcindo Antônio; Hugo, Fernando Neves
This cross-sectional study aimed to evaluate the association between sociodemographic characteristics, health care indicators, work process characteristics, and the performance of preventive dental procedures by oral health care teams (OHCTs) assessed during the first phase of the PMAQ in Brazil. A census of 10 334 primary OHCTs was conducted. The outcome included topical application of fluoride, application of sealants, detection of oral lesions, and monitoring of suspected or confirmed cases of oral cancer. The multilevel Poisson regression model was used to obtain crude and adjusted prevalence ratios. The performance of preventive dental procedures was 29.46% (3044/10 334; 95% confidence interval, 28.57-30.33), which was considered low.
Leslie, Hannah H; Bitton, Asaf; Jerome, J Gregory; Thermidor, Roody; Joseph, Jean Paul; Kruk, Margaret E
Abstract Objective To develop a composite measure of primary care quality and apply it to Haiti’s primary care system. Methods Using the Primary Health Care Performance Initiative’s framework, we defined four domains of primary care service delivery: (i) accessible care; (ii) effective service delivery; (iii) management and organization; and (iv) primary care functions. We gave each primary care facility in Haiti a quality score for each domain and overall, with poor, fair and good quality indicated by scores of 0.00–0.49, 0.50–0.74 and 0.75–1.00, respectively. We quantified access and effective access to primary care as the proportions of the population within 5 km of any primary care facility and a good facility, respectively. Findings Of the 786 primary care facilities in Haiti in 2013, only 332 (43%) facilities were classified as good for accessible care. Fewer facilities were classified as good in the domains of effective service delivery (30; 4%), management and organization (91; 12%) and primary care functions (43; 5%). Although about 91% of the population lived within 5 km of a primary care facility, only an estimated 23% of the entire population – including just 5% of the rural population – had access to primary care of good quality. Conclusion Despite an extensive network of health facilities, a minority of Haitians had access to a primary care facility of good quality. Such facilities were especially scarce in rural areas. Similar systematic analyses of the quality of primary care could inform national efforts to strengthen health systems. PMID:28250531
Johnson-Agbakwu, Crista E.; Allen, Jennifer; Nizigiyimana, Jeanne F.; Ramirez, Glenda; Hollifield, Michael
Posttraumatic stress disorder (PTSD), anxiety, and depression are the most common mental health disorders in the refugee population. High rates of violence, trauma, and PTSD among refugee women remain unaddressed. The process of implementing a mental health screening tool among multi-ethnic, newly-arrived refugee women receiving routine obstetric and gynecologic care in a dedicated refugee women’s health clinic is described. The Refugee Health Screener-15 (RHS-15) is a culturally-responsive, efficient, validated screening instrument that detects symptoms of emotional distress across diverse refugee populations and languages. An interdisciplinary community partnership was established with a local behavioral health services agency to facilitate the referral of women scoring positive on the RHS-15. Staff and provider training sessions, as well as the incorporation of bi-cultural, multi-lingual Cultural Health Navigators, greatly facilitated linguistically-appropriate care coordination for refugee women in a culturally sensitive manner. Twenty-six (23.2%) of the 112 women who completed the RHS-15 scored positive; of which 14 (53.8%) were Iraqi, one (3.8%) was Burmese, and three (11.5%) were Somali. Among these 26 women, eight (30.8%) are actively receiving mental health services, and five (19.2%) have appointments scheduled. However 13 (50%) are not enrolled in mental health care due to either declining services (46.2%), or a lack of insurance (53.8%). Screening for mental disorders among refugee women will promote greater awareness and identify those individuals who would benefit from further mental health evaluation and treatment. Sustainable interdisciplinary models of care are necessary to promote health education, dispel myths and reduce the stigma of mental health. PMID:25383999
Johnson-Agbakwu, Crista E; Allen, Jennifer; Nizigiyimana, Jeanne F; Ramirez, Glenda; Hollifield, Michael
Posttraumatic stress disorder (PTSD), anxiety, and depression are common mental health disorders in the refugee population. High rates of violence, trauma, and PTSD among refugee women remain unaddressed. The process of implementing a mental health screening tool among multiethnic, newly arrived refugee women receiving routine obstetric and gynecologic care in a dedicated refugee women's health clinic is described. The Refugee Health Screener-15 (RHS-15) is a culturally responsive, efficient, validated screening instrument that detects symptoms of emotional distress across diverse refugee populations and languages. An interdisciplinary community partnership was established with a local behavioral health services agency to facilitate the referral of women scoring positive on the RHS-15. Staff and provider training sessions, as well as the incorporation of bicultural, multilingual cultural health navigators, greatly facilitated linguistically appropriate care coordination for refugee women in a culturally sensitive manner. Twenty-six (23.2%) of the 112 women who completed the RHS-15 scored positive, of which 14 (53.8%) were Iraqi, 1 (3.8%) was Burmese, and 3 (11.5%) were Somali. Among these 26 women, 8 (30.8%) are actively receiving mental health services and 5 (19.2%) have appointments scheduled. However, 13 (50%) are not enrolled in mental health care because of either declining services (46.2%) or a lack of insurance (53.8%). Screening for mental disorders among refugee women will promote greater awareness and identify those individuals who would benefit from further mental health evaluation and treatment. Sustainable interdisciplinary models of care are necessary to promote health education, dispel myths, and reduce the stigma of mental health.
Ruymán Brito-Brito, Pedro; Rodríguez-Ramos, Mercedes; Pérez-García-Talavera, Carlos
This is the case of a 61-year-old patient woman that visits her nurse in Primary Health Care to get the control of blood pressure and glycemia. In the last two years has suffered the loss of her husband and of two brothers beside having lived through other vital stressful events that have taken her to a situation of complicated grief. The care plan is realized using the M. Gordon assessment system and standardized languages NANDA, NOC and NIC. The principal aims were the improvement of the depression level and the improvement in the affliction resolution. As suggested interventions were proposed to facilitate the grief and the derivation to a mental health unit. A follow-up of the patient was realized in nursing consultation at Primary health care to weekly intervals, in the beginning, and monthly, later. The evaluation of the care plan reflects an improvement in the criteria of Prigerson's complicated grief; an increase of the recreative activities; the retreat of the mourning that still she was guarding; as well as an improvement in the control of the blood pressure numbers. The attention of nurses before a case of complicated grief turns out to be complex. Nevertheless the suitable accomplishment of certain interventions orientated to facilitating the grief, with a follow-up in consultation, shows the efficiency. The difficulty in the boarding of the psychosocial problems meets increased at the moment of are necessary the nursing diagnostics adapted for every individual case. The work in group between nurses could improves the consensus.
Álvarez Calatayud, Guillermo; Azpiroz, Fernando
Probiotics are used in a great number of both paediatric and adult diseases, mainly in gastrointestinal disorders, like diarrhoea. Nevertheless, their beneficial effect on immune alterations, such as atopic dermatitis and, more recently, in women related diseases such as vulvovaginitis and mastitis have also been observed. However, the use of probiotics is not completely implemented into the routine clinical practice for primary care physicians. There is still a great controversy with scarce scientific evidence, due to the diversity in the designs thereof which justifies the variability in the efficacy results. This outcome leads to difficulties in developing definitive treatment guidelines although there are exceptions, for example, WGO. The aim of this workshop, held at the VI Congress of the Spanish Society of Probiotics and Prebiotics is the training of primary care physicians, both paediatricians and general practitioners in the clinical applications of these nutritional preparations in different diseases: acute diarrhoea; antibiotic associated diarrhoea, necrotizing enterocolitis, employment in infant milk formulas, infant colic, irritable bowel syndrome and inflammatory bowel disease, as well as vulvovaginitis and mastitis.
Chen, Jonathan H.; Hom, Jason; Richman, Ilana; Asch, Steven M.; Podchiyska, Tanya; Johansen, Nawal Atwan
Abstract Long-term opioid use for noncancer pain is increasingly prevalent yet controversial given the risks of addiction, diversion, and overdose. Prior literature has identified the problem and proposed management guidelines, but limited evidence exists on the actual effectiveness of implementing such guidelines in a primary care setting. A multidisciplinary working group of institutional experts assembled comprehensive guidelines for chronic opioid prescribing, including monitoring and referral recommendations. The guidelines were disseminated in September 2013 to our medical center's primary care clinics via in person and electronic education. We extracted electronic medical records for patients with noncancer pain receiving opioid prescriptions (Rxs) in seasonally matched preintervention (11/1/2012–6/1/2013) and postintervention (11/1/2013–6/1/2014) periods. For patients receiving chronic (3 or more) opioid Rxs, we assessed the rates of drug screening, specialty referrals, clinic visits, emergency room visits, and quantity of opioids prescribed. After disseminating guidelines, the percentage of noncancer clinic patients receiving any opioid Rxs dropped from 3.9% to 3.4% (P = 0.02). The percentage of noncancer patients receiving chronic opioid Rxs decreased from 2.0% to 1.6% (P = 0.03). The rate of urine drug screening increased from 9.2% to 17.3% (P = 0.005) amongst noncancer chronic opioid patients. No significant differences were detected for other metrics or demographics assessed. An educational intervention for primary care opioid prescribing is feasible and was temporally associated with a modest reduction in overall opioid Rx rates. Provider use of routine drug screening increased, but overall rates of screening and specialty referral remained low despite the intervention. Despite national pressures to introduce opioid prescribing guidelines for chronic pain, doing so alone does not necessarily yield substantial changes in clinical
Watzke, Birgit; Rüddel, Heinz; Jürgensen, Ralph; Koch, Uwe; Kriston, Levente; Grothgar, Barbara; Schulz, Holger
We investigated the comparative effectiveness of cognitive-behavioural (CBT) and psychodynamic therapy (PDT) under clinically representative conditions as a subtrial of a prior study (Watzke et al., 2010, BJP). A consecutive sample of 147 patients with common mental disorders was randomised to either CBT or PDT in routine mental health care. In a primary per-protocol analysis patients randomised to CBT had a significantly better longer term outcome in the primary outcome symptom severity (General Severity Index of the SCL-14; p=.001; partial η(2)=0.073) as well as in health related quality of life (Mental Component Summary of the SF-8; p=.013; partial η(2)=.041) and concerning interpersonal issues (Inventory of Interpersonal Problems, IIP-C; p=.001; partial η(2)=.070) 6 months after treatment than patients randomised to PDT. These results could be confirmed in intention-to-treat analyses (n=180) suggesting that there was no substantial attrition bias due to drop outs at the follow-up assessment. Thus, the so called equivalence outcome paradox was not replicated in this study.
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.
Ricketts, T C
Rural primary care programs were established in areas where there was thought to be no competition for patients. However, evidence from site visits and surveys of a national sample of subsidized programs revealed a pattern of competitive responses by the clinics. In this study of 193 rural primary care programs, mail and telephone surveys produced uniform data on the organization, operation, finances, and utilization of a representative sample of clinics. The programs were found to compete in terms of: (1) price, (2) service mix, (3) staff availability, (4) structural accessibility, (5) outreach, and (6) targeting a segment of the market. The competitive strategies employed by the clinics had consequences that affected their productivity and financial stability. The strategies were related to the perceived missions of the programs, and depended heavily upon the degree of isolation of the program and the targeting of the services. The competitive strategy chosen by a particular program could not be predicted based on service area population and apparent competitors in the service area. The goals and objectives of the programs had more to do with their competitive responses than with market characteristics. Moreover, the chosen strategies may not meet the demands of those markets.
Joiner, Terence A.; Cowan, Anne E.; Stringer, Sonja M.; Akbar, Jabar
OBJECTIVE: The purpose of this study is to determine primary care pediatricians' level of awareness in the diagnosis and management of rickets. The information will be useful in assessing the need for provider education related to appropriate advice regarding vitamin D supplementation for infants. STUDY DESIGN: A one-page questionnaire was sent to a sample of 510 pediatricians in states surrounding the Great Lakes. These physicians were chosen depending based on practice listings from local telephone directories. Results were analyzed using the Chi-squared (chi2) test. RESULTS: Of the 248 respondents, 43% (n = 105) had encountered at least one actual or suspected case of rickets in the past five years. Sixty-nine percent of respondents chose vitamin D deficiency rickets-specific diagnostic tests, 24% chose rickets-specific tests, and 7% chose tests that are not specific to diagnosing rickets. Ninety-four percent of respondents chose treatments specific to vitamin D deficiency rickets, while 6% chose treatments not specific to rickets. CONCLUSION: Most primary care pediatricians from major metropolitan areas in the Great Lakes region are aware of the appropriate methods to diagnose and treat vitamin D-deficiency rickets. However, educational interventions are still necessary for both physicians and parents to promote widespread use of vitamin D supplementation in all breastfed infants. PMID:12443000
Catalán, Arantxa; Borrell, Francesc; Pons, Angels; Amado, Ester; Baena, José Miguel; Morales, Vicente
The Institut Català de la Salut (ICS) has designed and integrated in electronic clinical station of primary care a new software tool to support the prescription of drugs, which can detect on-line certain medication errors. The software called PREFASEG (stands for Secure drug prescriptions) aims to prevent adverse events related to medication use in the field of primary health care (PHC). This study was made on the computerized medical record called CPT, which is used by all PHC physicians in our institution -3,750- and prescribing physicians through it. PREFASEG integrated in eCAP in July 2010 and six months later we performed a cross-sectional study to evaluate their usefulness and refine their design. The software alerts on-line in 5 dimensions: drug interactions, redundant treatments, allergies, contraindications of drugs with disease, and advises against drugs in over 75 years. PREFASEG generated 1,162,765 alerts (1 per 10 high treatment), with the detection of therapeutic duplication (62%) the most alerted. The overall acceptance rate is 35%, redundancies pharmacological (43%) and allergies (26%) are the most accepted. A total of 10,808 professionals (doctors and nurses) have accepted some of the recommendations of the program. PREFASEG is a feasible and highly efficient strategy to achieve an objective of Quality Plan for the NHS.
Brenes Bermúdez, F J; Cozar Olmo, J M; Esteban Fuertes, M; Fernández-Pro Ledesma, A; Molero García, J M
Despite the high incidence of urinary incontinence (UI), health professional awareness of this disease is low, which in itself is not serious but significantly limits the lives of the patients. The Primary Care associations, Sociedad Española de Médicos de Atención Primaria [SEMERGEN], Sociedad Española de Médicos Generales y de Familia [SEMG], Sociedad Española de Medicina de Familia y Comunitaria [semFYC]) along with the Asociación Española de Urología (EAU) have developed this consensus with the proposal of making GPs aware, and to help them in the diagnosis, treatment and referral to Urologists. The first goal in primary care must be the detection of UI, thus an opportunistic screening at least once in the lifetime of asymptomatic women > 40 years old and asymptomatic men > 55 years old. The diagnosis, based on medical history and physical examination, must determine the type and severity of the UI in order to refer severe cases to the Urologist. Except for overactive bladder (OAB), non-pharmacological conservative treatment is the first approach to uncomplicated UI in females and males. Antimuscarinics are the only drugs that have demonstrated efficacy and safety in urge urinary incontinence (UUI) and OAB. In men with mixed symptoms, excluding severe obstruction cases, a combination therapy of alpha-blockers and antimuscarinics should be chosen.
Brenes Bermúdez, F J; Cozar Olmo, J M; Esteban Fuertes, M; Fernández-Pro Ledesma, A; Molero García, J M
Despite the high incidence of urinary incontinence (UI), health professional awareness of this disease is low, which in itself is not serious but significantly limits the lives of the patients. The Primary Care associations, Sociedad Española de Médicos de Atención Primaria [SEMERGEN], Sociedad Española de Médicos Generales y de Familia [SEMG], Sociedad Española de Medicina de Familia y Comunitaria [semFYC]) along with the Asociación Española de Urología (EAU) have developed this consensus with the proposal of making GPs aware, and to help them in the diagnosis, treatment and referral to Urologists. The first goal in primary care must be the detection of UI, thus an opportunistic screening at least once in the lifetime of asymptomatic women > 40 years old and asymptomatic men > 55 years old. The diagnosis, based on medical history and physical examination, must determine the type and severity of the UI in order to refer severe cases to the Urologist. Except for overactive bladder (OAB), non-pharmacological conservative treatment is the first approach to uncomplicated UI in females and males. Antimuscarinics are the only drugs that have demonstrated efficacy and safety in urge urinary incontinence (UUI) and OAB. In men with mixed symptoms, excluding severe obstruction cases, a combination therapy of alpha-blockers and antimuscarinics should be chosen.
Beyer, Martin; Gerlach, Ferdinand M; Erler, Antje
In its 2009 report the Federal Advisory Council on the Assessment of Developments in the Health Care System developed a model of Primary Care Practices for future general practice-based primary care. This article presents the theoretical background of the model. Primary care practices are seen as developed organisations requiring changes at all system levels (interaction, organisation, and health system) to ensure sustainability of primary care functions in the future. Developments of the elements comprising the health care system may be compared to the developments and proposals observed in other countries. In Germany, however, the pace of these developments is relatively slow.
Kemp, Kathleen; Zelle, Heather; Bonnie, Richard J
For people with serious mental illness, research demonstrates the potential positive effects of having an advance directive with specific instructions for mental health care. The Commonwealth of Virginia has undertaken efforts to incorporate the completion of psychiatric advance directives into routine mental health services for individuals with serious mental illness. The inherent complexities of advance directives-a single legal tool for use by a heterogeneous array of consumers, providers, and organizations-have led to more barriers than had been anticipated. This article describes challenges encountered in the first three years of implementation efforts. Data are from feedback on early training attempts and experiences of staff at pilot sites and work groups convened for the implementation project. The authors describe a range of challenges, such as how to present a complete and clear message about the nature, purposes, and potential advantages of psychiatric advance directives to various audiences, in particular their use in recovery-oriented care; how to promote cross-system collaboration among potential users of these directives; and how to overcome resource constraints and sustain interest in the process. Virginia's experience reinforces the importance of developing multifaceted implementation strategies, such as the creation of informational and training tools to spread implementation more effectively, the identification of "champions" or staff members who are invested in implementation, and the development of multiple approaches to facilitating completion of advance directives by consumers.
The health promotion discourse is comprised of assumptions about health and health care that are compatible with primary health care. An examination of the health promotion discourse illustrates how assumptions of health can help to inform primary health care. Despite health promotion being a good fit for primary health care, this analysis demonstrates that the scope in which it is being implemented in primary health care settings is limited. The health promotion discourse appears largely compatible with primary health care-in theory and in the health care practices that follow. The aim of this article is to contribute to the advancement of theoretical understanding of the health promotion discourse, and the relevance of health promotion to primary health care.
Peccoralo, Lauren A; Callahan, Kathryn; Stark, Rachel; DeCherrie, Linda V
With growing numbers of patient-centered medical homes and accountable care organizations, and the potential implementation of the Patient Protection and Affordable Care Act, the provision of primary care in the United States is expanding and changing. Therefore, there is an urgent need to create more primary-care physicians and to train physicians to practice in this environment. In this article, we review the impact that the changing US healthcare system has on trainees, strategies to recruit and retain medical students and residents into primary-care internal medicine, and the preparation of trainees to work in the changing healthcare system. Recruitment methods for medical students include early preclinical exposure to patients in the primary-care setting, enhanced longitudinal patient experiences in clinical clerkships, and primary-care tracks. Recruitment methods for residents include enhanced ambulatory-care training and primary-care programs. Financial-incentive programs such as loan forgiveness may encourage trainees to enter primary care. Retaining residents in primary-care careers may be encouraged via focused postgraduate fellowships or continuing medical education to prepare primary-care physicians as both teachers and practitioners in the changing environment. Finally, to prepare primary-care trainees to effectively and efficiently practice within the changing system, educators should consider shifting ambulatory training to community-based practices, encouraging resident participation in team-based care, providing interprofessional educational experiences, and involving trainees in quality-improvement initiatives. Medical educators in primary care must think innovatively and collaboratively to effectively recruit and train the future generation of primary-care physicians.
Nancarrow, Susan A
For over a decade, organizations have attempted to include the measurement and reporting of health outcome data in contractual agreements between funders and health service providers, but few have succeeded. This research explores the utility of collecting health outcomes data that could be included in funding contracts for an Australian Community Care Organisation (CCO). An action-research methodology was used to trial the implementation of outcome measurement in six diverse projects within the CCO using a taxonomy of interventions based on the International Classification of Function. The findings from the six projects are presented as vignettes to illustrate the issues around the routine collection of health outcomes in each case. Data collection and analyses were structured around Donabedian’s structure–process–outcome triad. Health outcomes are commonly defined as a change in health status that is attributable to an intervention. This definition assumes that a change in health status can be defined and measured objectively; the intervention can be defined; the change in health status is attributable to the intervention; and that the health outcomes data are accessible. This study found flaws with all of these assumptions that seriously undermine the ability of community-based organizations to introduce routine health outcome measurement. Challenges were identified across all stages of the Donabedian triad, including poor adherence to minimum dataset requirements; difficulties standardizing processes or defining interventions; low rates of use of outcome tools; lack of value of the tools to the service provider; difficulties defining or identifying the end point of an intervention; technical and ethical barriers to accessing data; a lack of standardized processes; and time lags for the collection of data. In no case was the use of outcome measures sustained by any of the teams, although some quality-assurance measures were introduced as a result of the
Mack, Dominic; Zhang, Shun; Douglas, Megan; Sow, Charles; Strothers, Harry; Rust, George
This study evaluates electronic health record (EHR) adoption by primary care providers in Georgia to assess adoption disparities according to practice size and type, payer mix, and community characteristics. Frequency variances of EHR “Go Live” status were estimated. Odds ratios were calculated by univariate and multivariate logistic regression models. Large practices and community health centers (CHCs) were more likely to Go Live (>80% EHR adoption) than rural health clinics and other underserved settings (53%). A significantly lower proportion (68.9%) of Medicaid predominant providers had achieved Go Live status and had a 47% higher risk of not achieving Go Live status than private insurance predominant practices. Disparities in EHR adoption rates may exacerbate existing disparities in health outcomes of patients served by these practices. Targeted support such as that provided to CHCs would level the playing field for practices now at a disadvantage. PMID:27587942
Elliott, Jennifer C; Aharonovich, Efrat; O'Leary, Ann; Wainberg, Milton; Hasin, Deborah S
Heavy drinking among individuals with HIV is associated with poor medication adherence and other health problems. Understanding reasons for drinking (drinking motives) in this population is therefore important and could inform intervention. Using concepts of drinking motives from previous alcohol research, we assessed these motives and drinking in 254 HIV-positive primary care patients (78.0 % male; 94.5 % African American or Hispanic) prior to their participation in an alcohol intervention trial. Three motives had good factor structure and internal consistency: "drinking to cope with negative affect", "drinking for social facilitation" (both associated with heavier drinking), and "drinking due to social pressure" (associated with less drinking). Drinking motives may provide important content for alcohol intervention; clinical trials could indicate whether inclusion of such content improves intervention efficacy. Discussing motives in session could help providers assist clients in better managing psychological and social aspects of their lives without reliance on alcohol.
Colon, Albert J; Ossenblok, Pauly; Nieuwenhuis, Lotte; Stam, Kees J; Boon, Paul
At present, in epilepsy, magnetoencephalography (MEG) is mostly used for presurgical evaluations. It has proven to be robust for detecting and localizing interictal epileptiform discharges. Whether this is also true for first-line investigation in the diagnosis of epilepsy has not been investigated yet. We present our data on the usefulness of MEG in the earliest phase of diagnosing epilepsy. We examined 51 patients with suspicion of neocortical epilepsy and an inconclusive routine EEG. A method to integrate MEG in daily routine was developed. Results of visually assessed MEG recordings were compared, retrospectively, with clinical data and with the results of EEG after sleep deprivation. After a finding of inconclusive, routine MEG generated a gain in diagnostic value of 63% when compared with "final" clinical diagnosis. This is comparable with the added value of EEG after sleep deprivation recorded previously in the same patients. However, MEG is less of a burden for patient and hospital and has no association with risk of increase in seizure frequency. The routine MEG with visual assessment only is a reliable diagnostic tool in the routine diagnosis of epilepsy and may replace or precede EEG after sleep deprivation in daily clinical practice. Furthermore, MEG together with MRI enables magnetic source imaging and, thus, may provide additional information on the cortical localization of the epilepsy of a patient.
Bono, Valerie; Amendola, Christine Lazaros
Primary care providers (PCPs) play a crucial role caring for patients with depression, managing antidepressant therapy, and assessing patients for suicide risk. Ten percent of the more than 20 million primary care visits for depression each year involve mental health issues, and account for 62% of the antidepressants prescribed in the United States. Psychiatric disorders appear to be underrecognized and undertreated in primary care. Suicidal ideation is present in a significant percentage of depressed primary care patients but rarely discussed. This article describes the warning signs and risk factors associated with suicide and recommends screening tools that can help PCPs identify patients at risk.
Poghosyan, Lusine; Lucero, Robert; Rauch, Lindsay; Berkowitz, Bobbie
For about 5 decades, nurse practitioners (NPs) have been utilized to deliver primary care, traditionally in underserved areas or to vulnerable populations. However, over the years, this workforce has experienced a steady growth and has expanded its reach to provide primary care in diverse settings. An additional 32 million patients will have access to primary care with full implementation of the Patient Protection and Affordable Care Act. It is unlikely that the scarce supply of primary care physicians will be able to properly meet the demand and the health care needs of the nation. NPs face challenges but practice, policy, and research recommendations for better utilizing NPs in primary care can mediate the workforce shortages and meet the demand for care.
Moore, Gordon; Showstack, Jonathan
Primary care is in crisis. Despite its proud history and theoretical advantages, the field has failed to hold its own among medical specialties. While the rest of medicine promises technology and sophistication, the basic model of primary care has changed little over the past half-century. Why has the transition from general practice to today's primary care been so difficult? Many of the causes of this struggle may lie within primary care itself, ranging from failure to articulate to the public (and insurers and policymakers) what value it, and it alone, can offer, to taking on an ever-broadening set of roles and responsibilities while all too often falling short of its promises. Perhaps most important, in the emerging health care system, the lack of a discrete definition of primary care has allowed managed care organizations and payers, among others, to define the role of primary care to suit their own interests. In response to a changing marketplace, political uncertainty, and shifting consumer expectations, primary care will need to reconstruct itself. The reconstruction will not be easy. Nevertheless, a process should begin that moves the field in the right direction. Building on its unique abilities, primary care can emerge as a redefined product that is attractive to patients, payers, and primary care practitioners alike.
Eisenberg, John M.
The organization and curricula of internal medicine residencies programs that emphasize primary care are described and compared with traditional residencies in internal medicine. It is noted that primary care residents spend more time in ambulatory care and are allowed more electives in specialties outside of internal medicine. Out-of-hospital…
This is a retrospective report on the importance of Kark and Cassel's 1952 paper on community-oriented primary care (COPC). In 1978, WHO and UNICEF endorsed COPC. However, the ideas girding and framing this approach had first been given full expression in practice some four decades earlier. In Depression-Era South Africa, Sidney Kark, a leader of the National Department of Health, converted the emergent discipline of social medicine into a unique form of comprehensive practice and established the Pholela Health Center, which was the explicit model for COPC. COPC as founded and practiced by Kark was a community, family and personal practice; it also was a multidisciplinary and team practice. Furthermore, the innovations of COPC entailed monitoring, evaluation, and research. Evaluation is the essence of Kark and Kassel's paper, which offers a convincing demonstration of the effects of COPC. Its key findings include the following: 1) that there was a decline in the incidence of syphilis in the area served by the health center; 2) that diet and nutrition improved; and 3) that the crude mortality rate as well as the infant mortality rate--the standard marker--declined in Pholela. In the succeeding decades, OPC had an international legacy (through WHO and H. Jack Geiger's influence in the US Office of Economic Opportunity), which came full circle in the 1980s, when a young generation of South Africans began to search their history for models for their health care programs at the dawn of the post-Apartheid Era.
Floriani, Ciro Augusto; Schramm, Fermin Roland
Palliative care, a model in end-of-life care, is currently undergoing expansion in Brazil. This article emphasizes the need to implement palliative care in primary health care, with an important role in end-of-life care, especially in areas without specialized palliative-care teams. The article discusses key aspects in the organization of this treatment modality and analyzes how palliative care could and should be implemented within primary health care in Brazil. The article describes several challenges for health teams to provide such care, related to the primary caregiver, inherent ethical conflicts, and human resource allocation.
White, Richard O.; Beech, Bettina M.; Miller, Stephania
IN BRIEF Disparities in diabetes care are prevalent in the United States. This article provides an overview of these disparities and discusses both potential causes and efforts to address them to date. The authors focus the discussion on aspects relevant to the patient-provider dyad and provide practical considerations for the primary care provider’s role in helping to diminish and eliminate disparities in diabetes care. PMID:21289869
Smith, R A; Mehra, S; Devereaux, M O; Rich, J
The MEDEX Primary Health Care Series, an integrated training system for everyone in primary care (PHC), was published in 1983. It is now used in over 70 countries and has demonstrated its value in the developing world. The Series lays considerable emphasis on the crucial link between the performance of health workers and the management support with which they are provided. It was the result of 10 years of development and field testing. The Series is so widely employed because its development involved health centers and health workers associated in PHC programs in Guyana, Lesotho, Micronesia, Pakistan, and Thailand. It also addresses everyday problems and provides pragmatic solutions which PHC programs can apply. Attention is given to the development of skills in health workers, using a competency-based methodology, in contrast to the concentration on knowledge acquition found in more conventional training programs. Training activities are detailed for as little as 15 minutes at a time in courses lasting 6-15 months. Dialogic methods are used for the more peripheral workers who may not be literate. Management is given systematic, practical treatment. The Series advocates disease prevention and health promotion and helps to train health workers to diagnose an treat the most common clinical problems. It can be used to strengthen existing programs or to start new ones. It has a consistent formant, facilitating local adaption. Any part of the Series can be copied or reproduced for noncommercial purposes without persmission from the publisher. The Series is based on the realistic and pragmatic organization of health care delivery systems found in most countries and places great importance on the use of health center presonnel to orientate and link resources at the center to needs at the periphery. Nurses, the health center person at the middle level of the PHC, often fulfills the role of trainer and supervisor of the community health worker. The diagnostic, curative and
Background Depression is a common mental disorder with a high burden of disease which is mainly treated in primary care. It is unclear to what extent stepped care principles are applied in routine primary care. The first aim of this explorative study was to examine the gap between routine primary depression care and optimal care, as formulated in the depression guidelines. The second aim was to explore the facilitators and barriers that affect the provision of optimal care. Methods Optimal care was operationalised by indicators covering the entire continuum of depression care: from prevention to chronic depression. Routine care was investigated by interviewing general practitioners (GPs) individually and together with other mental health care providers about the depression care they delivered collaboratively. Qualitative analysis of transcripts was performed using thematic coding. Additionally, the GPs completed a self-report questionnaire. Results Six GPs and 22 other (mostly primary) mental health care providers participated. The GPs and their primary care colleagues embraced a general stepped care approach. They offered psycho-education and counselling to mildly depressed patients. When the treatment effects were not satisfactory or patients were more severely depressed, the GPs offered, or referred to, psychotherapy or pharmacotherapy. Patients with a complex and severe depressive disorder were directly referred to specialised mental health care. However, GPs relied on their clinical judgment and rarely used instruments to assess and monitor the severity of depressive symptoms. Structured, evidence based interventions such as self-management and e-health were rarely offered to patients with depressive symptoms. Specific psychological interventions for relapse prevention or for chronically depressed patients were not available. A wide range of influencing factors for the provision of optimal depression care were put forward. Close collaboration with other mental
Bokulich, Nicholas A.; Mills, David A.
Premature infants in neonatal intensive care units (NICUs) are highly susceptible to infection due to the immaturity of their immune systems, and nosocomial infections are a significant risk factor for death and poor neurodevelopmental outcome in this population. To investigate the impact of cleaning within a NICU, a high-throughput short-amplicon-sequencing approach was used to profile bacterial and fungal surface communities before and after cleaning. Intensive cleaning of surfaces in contact with neonates decreased the total bacterial load and the percentage of Streptococcus species with similar trends for total fungal load and Staphylococcus species; this may have clinical relevance since staphylococci and streptococci are the most common causes of nosocomial NICU infections. Surfaces generally had low levels of other taxa containing species that commonly cause nosocomial infections (e.g., Enterobacteriaceae) that were not significantly altered with cleaning. Several opportunistic yeasts were detected in the NICU environment, demonstrating that these NICU surfaces represent a potential vector for spreading fungal pathogens. These results underline the importance of routine cleaning as a means of managing the microbial ecosystem of NICUs and of future opportunities to minimize exposures of vulnerable neonates to potential pathogens and to use amplicon-sequencing tools for microbial surveillance and hygienic testing in hospital environments. PMID:23740726
Hutchison, Brian; Levesque, Jean-Frederic; Strumpf, Erin; Coyle, Natalie
Context: During the 1980s and 1990s, innovations in the organization, funding, and delivery of primary health care in Canada were at the periphery of the system rather than at its core. In the early 2000s, a new policy environment emerged. Methods: This policy analysis examines primary health care reform efforts in Canada during the last decade, drawing on descriptive information from published and gray literature and from a series of semistructured interviews with informed observers of primary health care in Canada. Findings: Primary health care in Canada has entered a period of potentially transformative change. Key initiatives include support for interprofessional primary health care teams, group practices and networks, patient enrollment with a primary care provider, financial incentives and blended-payment schemes, development of primary health care governance mechanisms, expansion of the primary health care provider pool, implementation of electronic medical records, and quality improvement training and support. Conclusions: Canada's experience suggests that primary health care transformation can be achieved voluntarily in a pluralistic system of private health care delivery, given strong government and professional leadership working in concert. PMID:21676023
... care for babies, kids, and teens. Internists , or internal medicine doctors, care for adults, but some see patients ... have additional training in caring for teens. Combined internal medicine and pediatric specialists have training in both pediatrics ...
A systematic approach to Primary Care Performance Measurement is needed to provide useful information on a regular basis to inform planning, management and quality improvement at both the practice and system levels. Based on an environmental scan, a summit of primary care stakeholders and a stakeholder survey and supported by Measures and Technical Working Groups, the Ontario Primary Care Performance Measurement Steering Committee, representing 20 stakeholder organizations, identified system- and practice-level measurement priorities and related specific performance measures across nine domains of primary care performance. This initiative addressed measures' selection and technical specification. It did not include data collection. Lessons learned in Ontario can assist other jurisdictions developing frameworks for monitoring and reporting on primary care performance. Cross-country alignment could lead to a coordinated approach to measure and target areas for primary care performance improvement in Canada. PMID:28277205
Phillippi, Julia C; Bull, Amy; Holley, Sharon L
Many nurse practitioner specialties are requiring that basic primary care be included in their curricula. However, some experienced faculty within the specialty lack primary care experience. With a national shortage of nursing faculty, it is more important than ever to maximize available resources without overtaxing faculty workloads. Revision of our primary care practicum allowed nurse-midwifery faculty to lead a primary care clinical conference, using Family Nurse Practitioner (FNP) faculty as primary care experts. We revamped the clinical conference time to simulate clinical visits to guide the students through the clinical reasoning process. Low-fidelity simulation allowed students time to take a systematic approach to patient assessment, planning, and charting. The FNP "experts" were used to critique student chart notes prior to grading. This collaborative approach to the primary care clinical conference was well received by students, faculty, and preceptors and was quick and inexpensive to implement.
Smith, Michele S
Reviews the book, Integrated Psychological Services in Primary Care edited by William Scott Craig (see record 2016-01850-000). This book opens with an article by the editor, in which he outlines the behavioral health needs of primary care patients and the rationale behind integrating mental health services in primary care settings. Subsequent chapters address basic and practical information for a variety of practice locations, such as Patient Centered Medical Home clinics, the Veteran's Administration medical centers, and primary care settings where the concept of integrated health is new. This is an excellent primer for anyone planning to implement an integrated care program or for those considering moving from an independent practice, agency, or traditional health care/hospital environment into an integrated primary care environment. The authors' writing styles made difficult concepts easy to understand and their knowledge of the utility of integration was evident. (PsycINFO Database Record
Valentijn, Pim P.; Schepman, Sanneke M.; Opheij, Wilfrid; Bruijnzeels, Marc A.
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
Healthcare professionals in primary care are gatekeepers to specialist services and are important in terms of ensuring access to community support and appropriate referral for the sizable number of older people with mental health problems. This literature review explores the role of primary care professionals, particularly GPs and practice nurses, in diagnosing and managing patients with dementia. It recommends that education and training are required to raise awareness of the importance of accurate diagnosis and management in primary care.
Dunlop, Anne L; Wells, Jill Razor
A red eye is a common presenting complaint in the primary care setting. Redness of the eye indicates the presence of ocular inflammation, and most commonly represents benign conditions that can be readily treated by the primary care provider. However, there are emergent conditions that can present as a red eye. Primary care providers must readily recognize the danger signs that indicate these more serious ophthalmologic conditions that warrant immediate referral to an ophthalmologist.
Rost, K; Nutting, P A; Smith, J; Werner, J J
Complex interventions, which have been shown to improve primary care depression outcomes, are difficult to disseminate to routine practice settings. To address this problem, we developed a brief intervention to train primary care physicians and nurses employed by the practice to improve the detection and management of major depression. Before recruitment began, the research team conducted academic detailing conference calls with primary care physicians and nurses, and provided in-person training with nurses and administrative staff. Administrative staff screened over 11,000 patients before their visits to identify those with probable major depression. Primary care physicians delegated increased responsibility to office nurses, who educated over 90% of patients about effective depression treatment and systematically monitored their progress over time. Early results demonstrate that community primary care practices can rebundle traditional team roles over the short-term to provide more systematic mental health treatment without adding additional personnel. A rigorous evaluation of this effort will reduce time-consuming, expensive, and often unsuccessful efforts to "translate" research intervention findings into everyday practice.
Lee, Linda; Hillier, Loretta M; Molnar, Frank; Borrie, Michael J
Increasingly, primary care collaborative memory clinics (PCCMCs) are being established to build capacity for person-centred dementia care. This paper reflects on the significance of PCCMCs within the system of care for older adults, supported with data from ongoing evaluation studies. Results highlight timelier access to assessment with a high proportion of patients being managed in primary care within a person-centred approach to care. Enhancing primary care capacity for dementia care with interprofessional and collaborative care will strengthen the system's ability to respond to increasing demands for service and mitigate the growth of wait times to access geriatric specialist assessment.
Wong, Christopher J; Pagalilauan, Genevieve
Solid organ transplantation (SOT) is one of the major advances in medicine. Care of the SOT recipient is complex and continued partnership with the transplant specialist is essential to manage and treat complications and maintain health. The increased longevity of SOT recipients will lead to their being an evolving part of primary care practice, with ever more opportunities for care, education, and research of this rewarding patient population. This review discusses the overall primary care management of adult SOT recipients.
Phillips, Robert L.; Kaufman, Arthur; Mold, James W.; Grumbach, Kevin; Vetter-Smith, Molly; Berry, Anne; Burke, Bridget Teevan
The Affordable Care Act authorized, but did not fund, the Primary Care Extension Program (PCEP). Much like the Cooperative Extension Program of the US Department of Agriculture sped the modernization of farming a century ago, the PCEP could speed the transformation of primary care. It could also help achieve other goals such as integrating primary care with public health and translating research into practice. The urgency of these goals and their importance to achieving the Triple Aim for health care should increase interest in rapidly building the PCEP, much as the need to feed the country did a century ago. PMID:23508605
Psychologists frequently collaborate in the care of patients managed in primary care. Communication with a patient's primary care team is important to ensure coordination and continuity of care. The communication is far from seamless. Although The Health Information Privacy and Portability Act (HIPPA) is designed to promote sharing of clinical information while protecting patient confidentiality, unique problems arise when mental health records are included. Mental health records are subject to different regulations to protect the patient's confidentiality. Thus, what is communicated and how it will be accomplished are challenges. Further, psychologists and primary care providers often view documentation differently, resulting in different styles of documenting that may also impede coordinated care. Increasingly, health care systems are moving toward electronic medical records, creating greater opportunities for an integrated record. Improved communication through the record can keep other providers abreast of the mental health care being provided as well as suggestions they can use to reinforce the mental health care treatment plan.
Portillo, Carmen J; Stringari-Murray, Suzan; Fox, Christopher B; Monasterio, Erica; Rose, Carol Dawson
The increasing demand for primary care services and the current health care workforce shortage is predicted to cause drastic reductions in the number of clinicians who are competent to provide HIV care. For the past decade, the University of California, San Francisco (UCSF) School of Nursing has provided HIV specialty education for Advanced Practice Nursing students in the Master's curriculum. In 2013, UCSF was funded by the Health Resources Services Administration to establish a nurse practitioner (NP) HIV primary care education program to expand the number of NPs prepared to provide culturally appropriate comprehensive HIV primary care. To this end, UCSF faculty have developed and validated a set of HIV Primary Care entry-level NP competencies, integrated general HIV knowledge into the NP curriculum, and enhanced our current HIV Specialty curriculum and clinical training. Described herein is UCSF's Integrated HIV/AIDS Primary Care Capacity Nurse Practitioner Program.
Chapel, Helen; Prevot, Johan; Gaspar, Hubert Bobby; Español, Teresa; Bonilla, Francisco A.; Solis, Leire; Drabwell, Josina
Primary immune deficiencies (PIDs) are a growing group of over 230 different disorders caused by ineffective, absent or an increasing number of gain of function mutations in immune components, mainly cells and proteins. Once recognized, these rare disorders are treatable and in some cases curable. Otherwise untreated PIDs are often chronic, serious, or even fatal. The diagnosis of PIDs can be difficult due to lack of awareness or facilities for diagnosis, and management of PIDs is complex. This document was prepared by a worldwide multi-disciplinary team of specialists; it aims to set out comprehensive principles of care for PIDs. These include the role of specialized centers, the importance of registries, the need for multinational research, the role of patient organizations, management and treatment options, the requirement for sustained access to all treatments including immunoglobulin therapies and hematopoietic stem cell transplantation, important considerations for developing countries and suggestions for implementation. A range of healthcare policies and services have to be put into place by government agencies and healthcare providers, to ensure that PID patients worldwide have access to appropriate and sustainable medical and support services. PMID:25566243
Over the last decade, I have put together a new theory of leadership. This paper describes its four propositions, which are consistent with the research literature but which lead to conclusions that are not commonly held and seldom put into practice. The first proposition is a model describing the territory of leadership that is different from either the Leadership Qualities Framework, 2006 or the Medical Leadership Competency Framework, 2010, both of which have been devised specifically for the NHS (National Health Service). The second proposition concerns the ill-advised attempt of individuals to become expert in all aspects of leadership: complete in themselves. The third suggests how personality and capability are related. The fourth embraces and recommends the notion of complementary differences among leaders. As the NHS seeks increasing leadership effectiveness, these propositions may need to be considered and their implications woven into the fabric of NHS leader selection and development. Primary Health Care research, like all fields of collective human endeavour, is eminently in need of sound leadership and the same principles that facilitate sound leadership in other fields is likely to be relevant to research teams.
Shonkoff, J P; Dworkin, P H; Leviton, A; Levine, M D
Ninety-seven board certified pediatricians who spend at least 75% of their professional working hours involved in the delivery of primary care in New England were interviewed to explore their attitudes and current clinical approaches to developmental disabilities. The majority of the pediatricians relied exclusively on clinical judgment and general observations for assessing developmental problems in their offices. Responsibility for preschool screening for potential learning problems and the assessment of school failure were considered appropriate pediatric concerns. Reported customary approaches to a variety of developmental problems were not affected by the size of the practice nor by the socio-economic status of the patient population. Patterns of referral for consultation appeared to be more dependent on the nature of the suspected disorder than on the characteristics of the physicians or their practices. The need for more rigorous training in the developmental aspects of child health has been emphasized. In order to meet this challenge, more precise techniques for pediatric developmental assessment and more conclusive evaluations of specific interventions will have to be produced.
Reutter, Claudius A.; Robra, Bernt-Peter; Walther, Winfried
Background. Little is known about the clinical impact of new root canal preparation systems in general dental practice under routine care conditions. Therefore, we compared hand instrumentation (H) with Reciproc (R) (VDW, Munich, Germany) preparation. The outcomes were endodontic related pain and oral health related quality of life (OHRQoL), evaluation of the procedures by the patients and the strain felt by the dentists during root canal therapy. Methods. Six dentists participated in the trial as practitioner–investigators. In the first phase of the trial they prepared root canals with H and in the second phase with R. The patients documented their pain felt with a visual analogue scale (VAS 100) and OHRQoL with the German short version of the oral health impact profile (OHIP-G-14) before treatment and before the completion of therapy and answered questions about how they experienced the treatment. The dentists documented their physical strain during treatment. Results. A total of 137 patients were included in the evaluation. 66 patients were treated with H, 71 with R. Pain reduction was 32.6 (SD 32.9) VAS (H) vs. 29.4 (SD 26.9) VAS (R) (p = 0.550), and the improvement of the OHIP-14 score was 5.5 (SD 9.2) (H) vs. 6.7 (SD 7.4) (R) (p = 0.383). There were no statistical differences in both groups. Significantly fewer patients felt stressed by the duration of treatment with R as with H (p = 0.018). Significantly more dentists reported that their general physical strain and the strain on their fingers were less severe with R than with H (p = 0.013 and p < 0.001). Discussion. H as well as R effectively reduced endodontic related pain and OHRQoL without statistical differences. R has advantages in terms of how patients experience the treatment and regarding the physical strain felt by the dentists. PMID:27375972
Dekker, Andre; Vinod, Shalini; Holloway, Lois; Oberije, Cary; George, Armia; Goozee, Gary; Delaney, Geoff P.; Lambin, Philippe; Thwaites, David
Background and purpose A rapid learning approach has been proposed to extract and apply knowledge from routine care data rather than solely relying on clinical trial evidence. To validate this in practice we deployed a previously developed decision support system (DSS) in a typical, busy clinic for non-small cell lung cancer (NSCLC) patients. Material and methods Gender, age, performance status, lung function, lymph node status, tumor volume and survival were extracted without review from clinical data sources for lung cancer patients. With these data the DSS was tested to predict overall survival. Results 3919 lung cancer patients were identified with 159 eligible for inclusion, due to ineligible histology or stage, non-radical dose, missing tumor volume or survival. The DSS successfully identified a good prognosis group and a medium/poor prognosis group (2 year OS 69% vs. 27/30%, p < 0.001). Stage was less discriminatory (2 year OS 47% for stage I–II vs. 36% for stage IIIA–IIIB, p = 0.12) with most good prognosis patients having higher stage disease. The DSS predicted a large absolute overall survival benefit (~40%) for a radical dose compared to a non-radical dose in patients with a good prognosis, while no survival benefit of radical radiotherapy was predicted for patients with a poor prognosis. Conclusions A rapid learning environment is possible with the quality of clinical data sufficient to validate a DSS. It uses patient and tumor features to identify prognostic groups in whom therapy can be individualized based on predicted outcomes. Especially the survival benefit of a radical versus non-radical dose predicted by the DSS for various prognostic groups has clinical relevance, but needs to be prospectively validated. PMID:25241994
Pearson, P.; Jones, K.
The trio of recent government white papers heralds a new world for primary care. Many changes in the education of future primary health care professionals and in the research ethos of the discipline will be needed to realise this vision. New skills and attitudes, not least in multidisciplinary working; lifelong learning; and greater understanding of and participation in primary care research will have to emerge from educational efforts in the next few years. PMID:9081008
Monistrol, Olga; López, M Liboria; Riera, Montserrat; Font, Roser; Nicolás, Carme; Escobar, Miguel Angel; Freixas, Núria; Garau, Javier; Calbo, Esther
The hands of healthcare workers (HCWs) are the most common vehicle for the transmission of micro-organisms from patient to patient and within the healthcare environment. The aim of this study was to evaluate the impact of a multimodal campaign on the type and amount of resident and transient flora and the presence of potential risk factors for hand contamination during routine care. A before-after (PRE and POST periods) interventional study was carried out in medical wards of a tertiary care hospital. Eighty-nine samples were analysed. Samples were cultured immediately before patient contact using a glove-juice method. Data collected included socio-demographic and risk factors for hand contamination. Flora was measured as log10 c.f.u. ml(-1) and evaluated by comparing median values in the PRE and POST periods. Transient flora was isolated from the hands of 67.4 and 46.1 % of HCWs in the PRE and POST periods, respectively (P<0.001). Enterobacteriaceae, Pseudomonas spp. and meticillin-sensitive Staphylococcus aureus were the predominant contaminants. Resident flora was isolated from 92.1 % of HCWs in the PRE period and from 70.8 % in the POST period (P<0.001). The meticillin-resistant coagulase-negative staphylococci log10 c.f.u. count ml(-1) decreased from 1.96 ± 1.2 to 0.89 ± 1.2 (mean ± s d; P<0.001), and the global flora count decreased from 2.77 ± 1.1 to 1.56 ± 1.4 (P<0.001). In the POST period, the wearing of fewer rings (P<0.001), shorter fingernail length (P = 0.008), a shorter time since recent hand hygiene (HH) (P = 0.007) and an increased use of alcohol-based hand rub instead of soap (P<0.001) were documented. The HH multimodal strategy reduced the number of risk factors and the level of HCW hand contamination.
Martínez-Sabater, A; Sancho-Cantus, D
Rare diseases, due to their epidemiological characteristics, and sometimes to the non-specific symptoms, are difficult to diagnose routinely at Primary Care Level. A case is presented of Arnold Chiari malformation in a young male patient with early insidious presentation (neck pain and sub-occipital headaches) consulting due to the emergence of new symptoms (paresthesias, muscular weakness, cervicobrachial and radiating lumbar pain, and headaches after mild exertion).
Shrank, William H
Americans are increasingly demanding the same level of service in healthcare that they receive in other services and products that they buy. This rise in consumerism poses challenges for primary care physicians as they attempt to transform their practices to succeed in a value-based reimbursement landscape, where they are rewarded for managing costs and improving the health of populations. In this paper, three examples of consumer-riven trends are described: retail healthcare, direct and concierge care, and home-based diagnostics and care. For each, the intersection of consumer-driven care and the goals of value-based primary care are explored. If the correct payment and connectivity enablers are in place, some examples of consumer-driven care are well-positioned to support primary care physicians in their mission to deliver high-quality, efficient care for the populations they serve. However, concerns about access and equity make other trends less consistent with that mission.
Erikson, Clese E
Transformations in care delivery and payment models that make care more efficient are leading some to question whether there will really be a shortage of primary care physicians. While it is encouraging to see numerous federal and state policy levers in place to support greater accountability and coordination of care, it is too early to know whether these efforts will change current and future primary care physician workforce needs. More research is needed to inform whether efforts to reduce cost and improve quality of care and population health will help alleviate or further exacerbate expected primary care physician shortages.
Post, Edward P; Metzger, Maureen; Dumas, Patricia; Lehmann, Laurent
The Veterans Health Administration (VHA) has been undertaking a major transformational program of integrating collaborative mental health resources into primary care settings. Key components of the program include colocated collaborative care provided by mental health professionals; care management; and blended programs that combine elements of these two components, whose functions are highly complementary to each other. The program has grown since 2007 from an initiative implementing pilot programs at participating facilities, to a routine expectation of primary care within all VHA medical centers and large community-based outpatient clinics. The national program office supports this VHA initiative in multiple ways, including technical assistance to sites, program and policy development, dissemination of informational tools to facilitate continuous quality improvement, education and training, and partnerships with other existing and emerging VHA programs such as postdeployment health clinics and the patient-centered medical home.
Kleinsorge, Christy A; Roberts, Michael C; Roy, Kimberlee M; Rapoff, Michael A
A program evaluation of a pediatric primary care training clinic was conducted using the criteria of a "medical home" set forth by the American Academy of Pediatrics (AAP). A total of 107 parents completed questionnaires regarding demographics, satisfaction with care, and questions related to the definition of medical home. Medical providers completed questionnaires regarding demographics, job satisfaction, and community resources. Parents reported acceptable levels of satisfaction with the quality of care provided, and the essential parts of the medical home definition were met. There were several areas that were designated as having room for improvement, including shortening clinic wait times and instructing the medical providers to be more sensitive to cultural differences in beliefs about health and wellness. The concepts of medical home set forth by the AAP are attainable for pediatric primary care clinics, but routine evaluations may be needed to ensure that goals continue to be met.
Branch, William T., Jr.; And Others
The problems encountered, diagnostic procedures performed, and treatments prescribed in dermatology were studied in a primary care practice and in a dermatology clinic. It is proposed that the findings of this study be the basis for designing a curriculum in dermatology for residents in primary care medicine. (Author/MLW)
Skin cancer screening (SCS) promotes early detection and improves treatment. Primary care providers are strategically positioned to provide screenings, yet the frequency is low. Strategies to improve SCS include increasing skin cancer awareness, targeting high-risk patient populations, and advocating for primary care providers to conduct screenings.
In the main, writing about care seems to contrast the ethics of justice with the ethics of care. Whilst the former deploys objectivity, the latter holds that individuals are connected. Problematically, contemporary primary education seemingly holds a-personal, justice conceptions as its basis and rationale. In turn, primary education, in parts,…
Schiess, Nicoline; Ibrahim, Halah; Shaban, Sami; Perez, Maria Nichole; Nair, Satish Chandrasekhar
Background The low number of medical trainees entering primary care is contributing to the lack of access to primary care services in many countries. Despite the need for primary care physicians in the Middle East, there is limited information regarding trainees' career choices, a critical determinant in the supply of primary care physicians. Objective We analyzed the career choices of medical students in the United Arab Emirates (UAE), with a larger goal of reforming postgraduate training in the region and enhancing the focus on primary care. Methods We conducted a cross-sectional survey of applicants to a large established internal medicine residency program in the UAE. We calculated data for demographics, subspecialty choice, and factors affecting subspecialty choice, and we also reported descriptive statistics. Results Our response rate was 86% (183 of 212). Only 25% of applicants (n = 46) were interested in general internal medicine. The majority of respondents (n = 126, 69%) indicated a desire to pursue subspecialty training, and the remainder chose careers in research or administration. A majority of respondents (73%) were women, unmarried, and childless. Educational debt or lifestyle were not indicated as important factors in career choice. Conclusions Low interest in primary care was similar to that in many Western countries, despite a much higher percentage of female applicants and a reduced emphasis on lifestyle or income factors in career decisions. Reasons for the reduced interest in primary care deserve further exploration, as do tests of interventions to increase interest, such as improving the primary care clerkship experience. PMID:26692983
The Abbreviated Pandemic Influenza Plan Template for Primary Care Provider Offices is intended to assist primary care providers and office managers with preparing their offices for quickly putting a plan in place to handle an increase in patient calls and visits, whether during the 2009-2010 influenza season or future influenza seasons.
Hall, Mary Barbera
When a unit's staff changed from a team nursing to a primary nursing approach to care, the role of students gaining experience there changed to that of associate nurse, who is accountable for providing continuity of care to the primary nurses' patients. (Editor/TA)
Melville, C. A.; Finlayson, J.; Cooper, S.-A.; Allan, L.; Robinson, N.; Burns, E.; Martin, G.; Morrison, J.
Primary health care teams have an important part to play in addressing the health inequalities and high levels of unmet health needs experienced by people with intellectual disabilities (ID). Practice nurses have an expanding role within primary health care teams. However, no previous studies have measured their attitudes, knowledge, training…
If your medical group is seeing specialty costs spiral out of control in Medicare, a reverse capitation arrangement may help. Paying primary care providers fee-for-service--and specialty providers capitation--may better align your group's incentives and promote better use of low-cost primary care services for seniors. See if the methodology is right for you.
Meyer, William J.; Morrison, Patrick; Lombardero, Anayansi; Swingle, Kelsey; Campbell, Duncan G.
Unwillingness to share depression experiences with primary care physicians contributes to the undertreatment of depression. This project examined college students' reasons for depression nondisclosure to primary care providers (PCPs). Undergraduate participants read a vignette describing someone with depression and completed measures of disclosure…
Parker, A W; Walsh, J M; Coon, M
Primary care is the subject of many pronouncements and many recommendations for change in the literature on health care organization and delivery. Heretofore, there has been no attempt to assess the degree of agreement on the meaning of the term. This paper reports on a normative process used to construct 92 statements about important elements of primary care, and to rank these statements according to their relative degrees of importance in primary care. Three panels--nationally recognized "experts" on primary care, consumers, and public health nurses and social workers--participated in the development as well as the ranking of the statements. The rankings of the national experts are discussed in detail, and brief comparisons are made with the rankings of the consumer and public health worker panels. Experts gave a high ranking to the statements concerned directly with medical services and their linkages. All gave attention to equality and patient dignity. Consumers stressed the need to improve access to primary care services. Public health workers emphasized improvement in both access and the quality of the relationship between patients and providers. The overall findings suggest that increasing the base of participation in primary care planning may bring greater attention to patient defined needs, and that broadening of medical care objectives from medical care to a more inclusive health care is not imminent.
Gallo, Patrizia; Cioffi, Luigi; Limauro, Raffaele; Farris, Evelina; Bianco, Vincenzo; Sassi, Roberto; De Giovanni, Maria; Gallo, Valeria; D’Onofrio, Antonietta; Di Maio, Salvatore
Background: Epidemiologic evidences suggest a strong association between low birth weight and some diseases in adult life ( hypertension, diabetes, cardiovascular diseases).Aim of this study was to evaluate the obesity/overweight prevalence in a population of children born small for gestation age, SGA children 400, 208 males and 192 females compared to a population of children born appropriate for gestational age 6818 AGA children, 3502 males and 3316 females, during childhood. Our intention was also to build the natural history of weight gain during prepubertal age in children born SGA and AGA. Design and Methods: Observational prospective longitudinal study. We followed our patients from January2001 up to December 2010; weight, height and body mass index (BMI) were evaluated in all the SGA and AGA children. BMI z-score range for defining overweight and obesity was, respectively, 1.13 to 1.7 and >1.7 according to CDC growth charts. Results: In transversal evaluation, we prove that 10-year-old SGA females are twice obese and more overweight compared to equal age AGA females. In longitudinal evaluation, we highlight different observations: SGA children obese at 2 years are still obese at 10 years; the number of obese SGA children increases gradually until the age of 10; AGA children, appear to be less obese than SGA children at 10 years. Conclusion: SGA males and females are more obese at 5 and 10 years compared to the AGA population. Primary care pediatricians, through early detection of the children at risk, can carry out an effective obesity prevention project in SGA children. PMID:27583297
Slater, Morgan; Kiran, Tara
Abstract Objective To compare the characteristics and responses of patients completing a patient experience survey accessed online after e-mail notification or delivered in the waiting room using tablet computers. Design Cross-sectional comparison of 2 methods of delivering a patient experience survey. Setting A large family health team in Toronto, Ont. Participants Family practice patients aged 18 or older who completed an e-mail survey between January and June 2014 (N = 587) or who completed the survey in the waiting room in July and August 2014 (N = 592). Main outcome measures Comparison of respondent demographic characteristics and responses to questions related to access and patient-centredness. Results Patients responding to the e-mail survey were more likely to live in higher-income neighbourhoods (P = .0002), be between the ages of 35 and 64 (P = .0147), and be female (P = .0434) compared with those responding to the waiting room survey; there were no significant differences related to self-rated health. The differences in neighbourhood income were noted despite minimal differences between patients with and without e-mail addresses included in their medical records. There were few differences in responses to the survey questions between the 2 survey methods and any differences were explained by the underlying differences in patient demographic characteristics. Conclusion Our findings suggest that respondent demographic characteristics might differ depending on the method of survey delivery, and these differences might affect survey responses. Methods of delivering patient experience surveys that require electronic literacy might underrepresent patients living in low-income neighbourhoods. Practices should consider evaluating for nonresponse bias and adjusting for patient demographic characteristics when interpreting survey results. Further research is needed to understand how primary care practices can optimize electronic survey delivery methods to survey a
Jones, K. P.; Bain, D. J.; Middleton, M.; Mullee, M. A.
OBJECTIVES--To explore the morbidity of patients diagnosed as asthmatic in general practice, to examine the determinants of this morbidity, and to derive a simple morbidity screening tool for use in primary care. DESIGN--Patient interviews, lung function measurements, and data extraction from general practice case notes. SUBJECTS--300 asthmatic patients aged 5 to 65 years randomly selected from the repeat prescribing registers of three general practices in the Southampton area. MAIN OUTCOME MEASURES--Reported morbidity using a calculated index based on three questions (Are you in a wheezy or asthmatic condition at least once per week; Have you had time off work or school in the past year because of your asthma; Do you suffer from attacks of wheezing during the night?); mean forced expiratory volume in one second and mean peak expiratory flow (over a seven day period); diurnal variation in peak flow; and the relation of the morbidity index to lung function. RESULTS--Mean forced expiratory volume in one second was 67% predicted (SD 18.4), mean peak expiratory flow was 80% predicted (SD 18.9), and mean diurnal variation was 10% (SD 7.7). 76 subjects were classified as having low morbidity, 95 medium, and 125 high. The morbidity index was significantly associated with forced expiratory volume in one second, mean peak expiratory flow rate, and diurnal variation (p less than 0.05); it was not significantly associated with inhaler technique or use of prophylaxis. CONCLUSIONS--There was a large burden of persisting morbidity across all ages of patients diagnosed as asthmatic in the three well resourced practices studied. The use of the morbidity index may help to target the asthmatic patients needing more attention by concentrating on those reporting medium to high morbidity. PMID:1540736
Dubovsky, Amelia N; Kiefer, Meghan M
Borderline personality disorder is estimated to be present in approximately 6% of outpatient primary care settings. However, the time and energy spent on this population can greatly exceed what primary care doctors are able to spend. This article gives an overview of borderline personality disorder, including the clinical characteristics, epidemiology, and comorbidities, as well as pharmacologic and most important behavioral management. It is our hope that, with improved understanding of the disorder and skills for managing this population, caring for patients with the disorder can be more satisfying and less taxing for both primary care doctors and their patients.
Hutchison, B; Abelson, J; Lavis, J
The development of Canadian primary care has been shaped by a series of policy legacies that continue to affect the possibilities for change in primary care through their cumulative effects on the health care system and the process of health policy development. The pursuit of radical systemwide change in the face of unfavorable circumstances (created in large part by those legacies) has resulted in missed opportunities for cumulative incremental change. While major changes in primary care policy seem unlikely in the near future, significant incremental change is possible, but it will require a reorientation of the policy development process.
Stange, Kurt C; Etz, Rebecca S; Gullett, Heidi; Sweeney, Sarah A; Miller, William L; Jaén, Carlos Roberto; Crabtree, Benjamin F; Nutting, Paul A; Glasgow, Russell E
Metrics focus attention on what is important. Balanced metrics of primary health care inform purpose and aspiration as well as performance. Purpose in primary health care is about improving the health of people and populations in their community contexts. It is informed by metrics that include long-term, meaning- and relationship-focused perspectives. Aspirational uses of metrics inspire evolving insights and iterative improvement, using a collaborative, developmental perspective. Performance metrics assess the complex interactions among primary care tenets of accessibility, a whole-person focus, integration and coordination of care, and ongoing relationships with individuals, families, and communities; primary health care principles of inclusion and equity, a focus on people's needs, multilevel integration of health, collaborative policy dialogue, and stakeholder participation; basic and goal-directed health care, prioritization, development, and multilevel health outcomes. Environments that support reflection, development, and collaborative action are necessary for metrics to advance health and minimize unintended consequences.
Dorsey, E Ray; Nicholson, Sean; Frist, William H
The current medical education system and reimbursement policies in the United States have contributed to a maldistribution of physicians by specialty and geography. The causes of this maldistribution include financial barriers that prevent the individuals who would be the most likely to serve in primary care and underserved areas from entering the profession, large taxpayer subsidies to teaching hospitals that provide incentives to act in ways that are not in the best interest of society, and reimbursement policies that discourage physicians from providing primary care. The authors propose that the maldistribution of physicians can be addressed successfully by reducing the financial barriers to becoming a primary care physician, aligning subsidies with societal interests, and providing financial incentives that target primary care. They suggest that the Patient Protection and Affordable Care Act of 2010 takes steps in the right direction but that more financially prudent measures should be taken as politicians revisit health care reform with heightened financial scrutiny.
Freeman, Jan Sweet
Integrated primary care in a patient-centered medical home is the best way to invite patients to engage in better self-care, to move from provider-based care to team-based care, and to address whole-person needs. However, primary care-whether rural or urban, public or private-cannot become the default mental health system for North Carolinians with severe mental illness.
Chen, Shui-Wen; Fu, Wei; Liu, Jing; Wang, Yan
Abstract The aim of this study was to study the features of lung ultrasonography (LUS) in lung disease and to evaluate the usefulness of LUS in the neonatal intensive care unit (NICU). All of 3405 neonates included in this study underwent an LUS examination. Diagnoses were based on medical history, clinical manifestation, laboratory examination, and signs on chest radiography (CR) and/or computed tomography (CT). A single expert physician performed all LUS examinations. There were 2658 cases (78.9%) with lung disease and 747 cases (21.9%) without lung disease. The main signs of neonates with lung disease on LUS were as follows: absence of A-lines, pleural-line abnormalities, interstitial syndrome, lung consolidation, air bronchograms, pulmonary edema, and lung pulse. These abnormal signs were reduced or eliminated on LUS as patient conditions improved. There were 81 cases that could not be diagnosed as lung disease by CR but were discovered as pneumonia, respiratory distress syndrome (RDS), or transient tachypnea of newborn (TTN) on LUS. Likewise, 23 cases misdiagnosed as RDS by CR were diagnosed as TTN on LUS. Among 212 cases of long-term oxygen dependence (LTOD) that failed to yield signs of pulmonary edema and lung consolidation on CR, 103 cases showed abnormal signs on LUS. Among 747 cases without lung disease, B-lines of 713 neonates (95.4%) could be found within 3 days after birth, and 256 neonates (34.3%) could be observed from 3 days to 1 week after birth. B-lines of 19 cases could be detected from 1 to 2 weeks after birth. The longest time at which B-lines could still be observed was 19 days after birth. LUS has clinical value for the diagnosis of lung disease and the discrimination of causes of LTOP in premature infants, particularly for the diagnosis and identification of RDS and TTN. Moreover, LUS has additional advantages, including its lack of radiation exposure and its ability to noninvasively monitor treatment progress. Therefore, LUS should be
Chen, Shui-Wen; Fu, Wei; Liu, Jing; Wang, Yan
The aim of this study was to study the features of lung ultrasonography (LUS) in lung disease and to evaluate the usefulness of LUS in the neonatal intensive care unit (NICU).All of 3405 neonates included in this study underwent an LUS examination. Diagnoses were based on medical history, clinical manifestation, laboratory examination, and signs on chest radiography (CR) and/or computed tomography (CT). A single expert physician performed all LUS examinations.There were 2658 cases (78.9%) with lung disease and 747 cases (21.9%) without lung disease. The main signs of neonates with lung disease on LUS were as follows: absence of A-lines, pleural-line abnormalities, interstitial syndrome, lung consolidation, air bronchograms, pulmonary edema, and lung pulse. These abnormal signs were reduced or eliminated on LUS as patient conditions improved. There were 81 cases that could not be diagnosed as lung disease by CR but were discovered as pneumonia, respiratory distress syndrome (RDS), or transient tachypnea of newborn (TTN) on LUS. Likewise, 23 cases misdiagnosed as RDS by CR were diagnosed as TTN on LUS. Among 212 cases of long-term oxygen dependence (LTOD) that failed to yield signs of pulmonary edema and lung consolidation on CR, 103 cases showed abnormal signs on LUS. Among 747 cases without lung disease, B-lines of 713 neonates (95.4%) could be found within 3 days after birth, and 256 neonates (34.3%) could be observed from 3 days to 1 week after birth. B-lines of 19 cases could be detected from 1 to 2 weeks after birth. The longest time at which B-lines could still be observed was 19 days after birth.LUS has clinical value for the diagnosis of lung disease and the discrimination of causes of LTOP in premature infants, particularly for the diagnosis and identification of RDS and TTN. Moreover, LUS has additional advantages, including its lack of radiation exposure and its ability to noninvasively monitor treatment progress. Therefore, LUS should be routinely used
There has been serious concern about the nutritional care provided in some secondary and primary care settings. As a result, best practice, benchmarking initiatives and nutritional guidance have been issued by government and non-government agencies. This article helps nurses to synthesise these initiatives and improve their knowledge of nutritional care.
Steiner, Rose M.; Walsworth, David T.
Introduction: Improving Performance in Practice (IPIP) is an initiative convened by the American Board of Medical Specialties. It investigates the efficacy of coaches in helping primary-care practices improve the care of patients with diabetes and asthma. Most IPIP states use coaches who have a health care background, and are trained in quality…
Salvador Comino, María Rosa; Krane, Sibylla; Schelling, Jörg; Regife García, Víctor
An efficient primary care is of particular importance for any countries' health care system. Many differences exist on how distinctive countries try to obtain the goal of an efficient, cost-effective primary care for its population. In this article we conducted a selective literature review, which includes both scientific and socio-political publications. The findings are complemented with the experience of a Spanish physician from Seville in her last year of training in family medicine, who completed a four months long rotation in the German health care system. We highlighted different features by comparing both countries, including their health care expenditure, the relation between primary and secondary care, the organization in the academic field and the training of future primary care physicians. It is clear that primary care in both countries plays a central role, have to deal with shortcomings, and in some points one system can learn from the other.
Background There is increasing evidence that a strong primary care is a cornerstone of an efficient health care system. But Switzerland is facing a shortage of primary care physicians (PCPs). This pushed the Federal Council of Switzerland to introduce a multifaceted political programme to strengthen the position of primary care, including its academic role. The aim of this paper is to provide a comprehensive overview of the situation of academic primary care at the five Swiss universities by the end of year 2012. Results Although primary care teaching activities have a long tradition at the five Swiss universities with activities starting in the beginning of the 1980ies; the academic institutes of primary care were only established in recent years (2005 – 2009). Only one of them has an established chair. Human and financial resources vary substantially. At all universities a broad variety of courses and lectures are offered, including teaching in private primary care practices with 1331 PCPs involved. Regarding research, differences among the institutes are tremendous, mainly caused by entirely different human resources and skills. Conclusion So far, the activities of the existing institutes at the Swiss Universities are mainly focused on teaching. However, for a complete academic institutionalization as well as an increased acceptance and attractiveness, more research activities are needed. In addition to an adequate basic funding of research positions, competitive research grants have to be created to establish a specialty-specific research culture. PMID:24885148
Walley, John; Lawn, Joy E; Tinker, Anne; de Francisco, Andres; Chopra, Mickey; Rudan, Igor; Bhutta, Zulfiqar A; Black, Robert E
The principles agreed at Alma-Ata 30 years ago apply just as much now as they did then. "Health for all" by the year 2000 was not achieved, and the Millennium Development Goals (MDGs) for 2015 will not be met in most low-income countries without substantial acceleration of primary health care. Factors have included insufficient political prioritisation of health, structural adjustment policies, poor governance, population growth, inadequate health systems, and scarce research and assessment on primary health care. We propose the following priorities for revitalising primary health care. Health-service infrastructure, including human resources and essential drugs, needs strengthening, and user fees should be removed for primary health-care services to improve use. A continuum of care for maternal, newborn, and child health services, including family planning, is needed. Evidence-based, integrated packages of community and primary curative and preventive care should be adapted to country contexts, assessed, and scaled up. Community participation and community health workers linked to strengthened primary-care facilities and first-referral services are needed. Furthermore, intersectoral action linking health and development is necessary, including that for better water, sanitation, nutrition, food security, and HIV control. Chronic diseases, mental health, and child development should be addressed. Progress should be measured and accountability assured. We prioritise research questions and suggest actions and measures for stakeholders both locally and globally, which are required to revitalise primary health care.
Misra, Vasundhra; Vashist, Praveen; Malhotra, Sumit; Gupta, Sanjeev K
Blindness and visual impairment continues to be a major public health problem in India. Availability and easy access to primary eye care services is essential for elimination of avoidable blindness. 'Vision 2020: The Right to Sight - India' envisaged the need for establishing primary eye care units named vision centers for every 50,000 population in the country by the year 2020. The government of India has given priority to develop vision centers at the level of community health centers and primary health centers under the 'National Program for Control of Blindness'. NGOs and the private sector have also initiated some models for primary eye care services. In the current situation, an integrated health care system with primary eye care promoted by government of India is apparently the best answer. This model is both cost effective and practical for the prevention and control of blindness among the underprivileged population. Other models functioning with the newer technology of tele-ophthalmology or mobile clinics also add to the positive outcome in providing primary eye care services. This review highlights the strengths and weaknesses of various models presently functioning in the country with the idea of providing useful inputs for eye care providers and enabling them to identify and adopt an appropriate model for primary eye care services.
Hussain, Tanvir; Chang, Hsien-Yen; Luu, Ngoc-Phuong; Pollack, Craig Evan
Background Improving continuity between primary care and cancer care is critical for improving cancer outcomes and curbing cancer costs. A dimension of continuity, we investigated how regularly patients receive their primary care and surgical care for colon cancer from the same hospital and whether this affects mortality and costs. Methods Using Surveillance, Epidemiology, and End Results Program Registry (SEER)-Medicare data, we performed a retrospective cohort study of stage I-III colon cancer patients diagnosed between 2000 and 2009. There were 23,305 stage I-III colon cancer patients who received primary care in the year prior to diagnosis and underwent operative care for colon cancer. Patients were assigned to the hospital where they had their surgery and to their primary care provider’s main hospital, and then classified according to whether these two hospitals were same or different. Outcomes examined were hazards for all-cause mortality, subhazard for colon cancer specific mortality, and generalized linear estimate for costs at 12 months, from propensity score matched models. Results Fifty-two percent of stage I-III colon patients received primary care and surgical care from the same hospital. Primary care and surgical care from the same hospital was not associated with reduced all-cause or colon cancer specific mortality, but was associated with lower inpatient, outpatient, and total costs of care. Total cost difference was $8,836 (95% CI $2,746–$14,577), a 20% reduction in total median cost of care at 12 months. Conclusions Receiving primary care and surgical care at the same hospital, compared to different hospitals, was associated with lower costs but still similar survival among stage I-III colon cancer patients. Nonetheless, health care policy which encourages further integration between primary care and cancer care in order to improve outcomes and decrease costs will need to address the significant proportion of patients receiving health care
Kripke, Clarissa Calliope
Disability is a natural part of the human experience. To maximize potential, adolescents with disabilities require multidisciplinary transition planning and life-skill training. Health care professionals can reduce barriers to accessing health care. They can encourage self-determination and connect patients to self-advocacy organizations. They can facilitate smooth transitions to adult health care services. Careful descriptions of a patient's baseline traits and function are critical, not only to assist in person centered planning processes, but to ensure that new caregivers and clinicians have the information they need to recognize changes in function or behavior that can signal illness.
Pyne, Jeffrey M; Rost, Kathryn M; Zhang, Mingliang; Williams, D Keith; Smith, Jeffrey; Fortney, John
OBJECTIVE To determine the incremental cost-effectiveness of a quality improvement depression intervention (enhanced care) in primary care settings relative to usual care. DESIGN Following stratification, we randomized 12 primary care practices to enhanced or usual care conditions and followed patients for 12 months. SETTING Primary care practices located in 10 states across the United States. PATIENTS/PARTICIPANTS Two hundred eleven patients beginning a new treatment episode for major depression. INTERVENTIONS Training the primary care team to assess, educate, and monitor depressed patients during the acute and continuation stages of their depression treatment episode over 1 year. MEASUREMENTS AND MAIN RESULTS Cost-effectiveness was measured by calculating incremental (enhanced minus usual care) costs and quality-adjusted life years (QALYs) derived from SF-36 data. The mean incremental cost-effectiveness ratio in the main analysis was $15,463 per QALY. The mean incremental cost-effectiveness ratios for the sensitivity analyses ranged from $11,341 (using geographic block variables to control for pre-intervention service utilization) to $19,976 (increasing the cost estimates by 50%) per QALY. CONCLUSIONS This quality improvement depression intervention was cost-effective relative to usual care compared to cost-effectiveness ratios for common primary care interventions and commonly cited cost-effectiveness ratio thresholds for intervention implementation. PMID:12823650
Fuller, Shannon M; Koester, Kimberly A; Guinness, Ryan R; Steward, Wayne T
Shared decision-making (SDM) is considered best practice in health care. Prior studies have explored attitudes and barriers/facilitators to SDM, with few specific to HIV care. We interviewed 53 patients in HIV primary care clinics in California to understand the factors and situations that may promote or hinder engagement in SDM. Studies in other populations have found that patients' knowledge about their diseases and their trust in providers facilitated SDM. We found these features to be more nuanced for HIV. Perceptions of personal agency, knowledge about one's disease, and trust in provider were factors that could work for or against SDM. Overall, we found that participants described few experiences of SDM, especially among those with no comorbidities. Opportunities for SDM in routine HIV care (e.g., determining antiretroviral therapy) may arise infrequently because of treatment advances. These findings yield considerations for adapting SDM to fit the context of HIV care.
Kerkhof, Marjan; Freeman, Daryl; Jones, Rupert; Chisholm, Alison; Price, David B
from routinely available, computerized primary care data. Further study is needed to validate the model in other patient populations. PMID:26609229
Introduction Osteoarthritis (OA) constitutes a growing public health burden and the most common cause of disability in the United States. Non-pharmacologic modalities and conservative pharmacologic therapies are recommended for the initial treatment of OA, including acetaminophen, and topical and oral non-steroidal anti-inflammatory drugs. However, safety concerns continue to mount regarding the use of these treatments and none have been shown to impact disease progression. Viscosupplementation with injections of hyaluronans (HAs) are indicated when non-pharmacologic and simple analgesics have failed to relieve symptoms (e.g., pain, stiffness) associated with knee OA. This review evaluates literature focusing on the efficacy and/or safety of HA injections in treating OA of the knee and in other joints, including the hip, shoulder, and ankle. Methods Relevant literature on intra-articular (IA) HA injections as a treatment for OA pain in the knee and other joints was identified through PubMed database searches from inception until January 2013. Search terms included “hyaluronic acid” or “hylan”, and “osteoarthritis”. Discussion Current evidence indicates that HA injections are beneficial and safe for patients with OA of the knee. IA injections of HAs treat the symptoms of knee OA and may also have disease-modifying properties, potentially delaying progression of OA. Although traditionally reserved for second-line treatment, evidence suggests that HAs may have value as a first-line therapy in the treatment of knee OA as they have been shown to be more effective in earlier stages and grades of disease, more recently diagnosed OA, and in less severe radiographic OA. Conclusion For primary care physicians who treat and care for patients with OA of the knee, IA injection with HAs constitutes a safe and effective treatment that can be routinely administered in the office setting. PMID:24203348
Srivastava, Anita; Kahan, Meldon; Nader, Maya
Abstract Objective To advise physicians on which treatment options to recommend for specific patient populations: abstinence-based treatment, buprenorphine-naloxone maintenance, or methadone maintenance. Sources of information PubMed was searched and literature was reviewed on the effectiveness, safety, and side effect profiles of abstinence-based treatment, buprenorphine-naloxone treatment, and methadone treatment. Both observational and interventional studies were included. Main message Both methadone and buprenorphine-naloxone are substantially more effective than abstinence-based treatment. Methadone has higher treatment retention rates than buprenorphine-naloxone does, while buprenorphine-naloxone has a lower risk of overdose. For all patient groups, physicians should recommend methadone or buprenorphine-naloxone treatment over abstinence-based treatment (level I evidence). Methadone is preferred over buprenorphine-naloxone for patients at higher risk of treatment dropout, such as injection opioid users (level I evidence). Youth and pregnant women who inject opioids should also receive methadone first (level III evidence). If buprenorphine-naloxone is prescribed first, the patient should be promptly switched to methadone if withdrawal symptoms, cravings, or opioid use persist despite an optimal buprenorphine-naloxone dose (level II evidence). Buprenorphine-naloxone is recommended for socially stable prescription oral opioid users, particularly if their work or family commitments make it difficult for them to attend the pharmacy daily, if they have a medical or psychiatric condition requiring regular primary care (level IV evidence), or if their jobs require higher levels of cognitive functioning or psychomotor performance (level III evidence). Buprenorphine-naloxone is also recommended for patients at high risk of methadone toxicity, such as the elderly, those taking high doses of benzodiazepines or other sedating drugs, heavy drinkers, those with a lower
Yehia, Baligh R; Long, Judith A; Stearns, Cordelia R; French, Benjamin; Tebas, Pablo; Frank, Ian
Participation in antiretroviral therapy clinical trials (ART-RCTs) offers many advantages including access to new drugs, close monitoring, and cost savings. These same benefits may pose a risk to patients ending ART-RCTs and returning to routine care; as they may experience changes to their drug regimen, decreased monitoring, and new out-of-pocket costs. We aimed to evaluate this transition and determine its effects on viral outcomes and patient perceptions. A retrospective cohort was assembled from participants of naïve ART-RCTs at the University of Pennsylvania between 1 January 2000 and 31 December 2009. Data were collected in the 12 months prior to and after trial completion. Multivariable logistic regression was used to evaluate viral failure rates and to identify factors associated with viral failure. Qualitative interviews were held with a subset of patients. Content analysis was used to identify thematic differences between patients with viral failure and those with viral suppression. In total, 116 patients enrolled in 5 ART-RCTs from 2000 to 2009. Viral failure was observed in 39 patients (34%). Nonwhites, high enrollment CD4 count, and trial completion in 1999-2002 were risk factors for failure. Patients transitioning from ART-RCTs to routine care had a 20% increased odds of failure (Adjusted Odds Ratio 1.20 (95% CI [0.37, 3.88])). Nine patients with viral suppression and three with viral failure in the year after trail completion were interviewed. Suppressed patients were more eager to continue trial participation, nervous about leaving the trial, and felt prepared to return to routine care. In contrast, those with viral failure were less concerned about the transition. These findings suggest that the posttrial period may be a vulnerable time for patients. Patients without a healthy fear of transitioning from ART-RCTs to routine care may be at increased risk of viral failure. Focus should be given to assisting patients during this transition.
Albalushi, Rima M; Sohrabi, Mohammad-Reza; Kolahi, Ali-Asghar
Background: To measure clients’ satisfaction with primary health care in the capital of Oman, Muscat, and also to identify the factors affecting their satisfaction. Methods: Through a cross-sectional study in health centers, 400 participants during the period from November 2009 to February 2010 were interviewed about their satisfaction degree with the primary health care services and setting. Four urban primary health care clinics from Muscat were selected randomly. Six domains of satisfaction including accessibility to services, continuity of care, humaneness of staff, comprehensiveness of care, provision of health education, and effectiveness of services were calculated from selected variables. The mean score of each area were calculated and then divided by the number of items in each area. Finally satisfaction areas were ranked based on recent criteria. Results: Mean age was 29.5 years (SD = 9.37) for male and 26.01 years (SD = 7.12) for female participants. All the areas were suitable and only continuity of care had negative score. The ranked areas of satisfaction were as humanness of staff, effectiveness of services, access to services, provision of health educational materials, comprehensiveness of care, continuity of care. Conclusions: Primary health care were accepted as a suitable strategy for providing health care among clients of urban health centers of Muscat. It can be recommended to other countries to use this as a choice for health care provision. PMID:23112898
Hochman, Michael; Asch, Steven M
Starfield and colleagues have suggested four overarching attributes of good primary care: "first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere." As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for high-needs, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.
... the Classroom What Other Parents Are Reading Your Child's Development (Birth to 3 Years) Feeding Your 1- to ... care. The best preventive care means forming a relationship with a PCP you like and trust, taking your child for scheduled checkups and vaccines , and following the ...
Burke, Triona; O'Neill, Catherine
Primary care health services in the Irish Republic have undergone fundamental transformation with the establishment of multidisciplinary primary care teams nationwide. Primary care teams provide a community-based health service delivered through a range of health professionals in an integrated way. As part of this initiative ten pilot teams were established in 2003. This research was undertaken in order to gain an understanding of nurse's experiences of working in a piloted primary care team. The methodology used was a focus group approach. The findings from this study illustrated how community nurse's roles and responsibilities have expanded within the team. The findings also highlighted the benefits and challenges of working as a team with various other community-based health-care disciplines.
Pesec, Madeline; Ratcliffe, Hannah L; Karlage, Ami; Hirschhorn, Lisa R; Gawande, Atul; Bitton, Asaf
Long considered a paragon among low- and middle-income countries in its provision of primary health care, Costa Rica reformed its primary health care system in 1994 using a model that, despite its success, has been generally understudied: basic integrated health care teams. This case study provides a detailed description of Costa Rica's innovative implementation of four critical service delivery reforms and explains how those reforms supported the provision of the four essential functions of primary health care: first-contact access, coordination, continuity, and comprehensiveness. As countries around the world pursue high-quality universal health coverage to attain the Sustainable Development Goals, Costa Rica's experiences provide valuable lessons about both the types of primary health care reforms needed and potential mechanisms through which these reforms can be successfully implemented.
Barry, Arden R.; Pammett, Robert T.
Background: In 2013, Jorgenson et al. published guidelines for pharmacists integrating into primary care teams. These guidelines outlined 10 evidence-based recommendations designed to support pharmacists in successfully establishing practices in primary care environments. The aim of this review is to provide a detailed, practical approach to implementing these recommendations in real life, thereby aiding to validate their effectiveness. Methods: Both authors reviewed the guidelines independently and ranked the importance of each recommendation respective to their practice. Each author then provided feedback for each recommendation regarding the successes and challenges they encountered through implementation. This feedback was then consolidated into agreed upon statements for each recommendation. Results and Discussion: Focusing on building relationships (with an emphasis on face time) and demonstrating value to both primary care providers and patients were identified as key aspects in developing these new roles. Ensuring that the environment supports the practice, along with strategic positioning within the clinic, improves uptake and can maximize the usefulness of a pharmacist in primary care. Demonstrating consistent and competent clinical and documentation skills builds on the foundation of the other recommendations to allow for the effective provision of clinical pharmacy services. Additional recommendations include developing efficient ways (potentially provider specific) to communicate with primary care providers and addressing potential preconceived notions about the role of the pharmacist in primary care. Conclusion: We believe these guidelines hold up to real-life integration and emphatically recommend their use for new and existing primary care pharmacists. PMID:27540404
McCall-Hosenfeld, Jennifer S; Weisman, Carol S; Perry, Amanda N; Hillemeier, Marianne M; Chuang, Cynthia H
Women in rural communities who are exposed to intimate partner violence (IPV) have fewer resources when seeking help due to limited health services, poverty, and social isolation. Rural primary care physicians may be key sources of care for IPV victims. The objective of this study was to assess the opinions and practices of primary care physicians caring for rural women with regard to IPV identification, the scope and severity of IPV as a health problem, how primary care providers respond to IPV in their practices, and barriers to optimized IPV care in their communities. Semistructured interviews were conducted with 19 internists, family practitioners, and obstetrician-gynecologists in rural central Pennsylvania. Interview transcripts were analyzed for major themes. Most physicians did not practice routine screening for IPV due to competing time demands, lack of training, limited access to referral services as well as low confidence in their effectiveness, and concern that inquiry would harm the patient-doctor relationship. IPV was considered when patients presented with symptoms of mood, anxiety, or somatic disorders. Responses to IPV included validation, danger assessment, safety planning, referral, and follow-up planning. Perceived barriers to rural women seeking help for IPV included traditional gender roles, lower education, economic dependence on the partner, low self-esteem, and patient reluctance to discuss IPV. To overcome barriers, physicians created a "safe sanctuary" to discuss IPV and suggested improved public health education and referral services. Interventions to improve IPV-related care in rural communities should address barriers at multiple levels, including both physicians' and patients' comfort with discussing IPV. Provider training, community education, and improved access to referral services are key areas in which IPV-related care should be improved in rural communities. Our data support routine screening to better identify IPV and a more
Swanson, K A; Swanson, J M; Gill, A E; Walter, C
Cuba's primary health care model is presented. Unlike ambulatory care services, which are but one component of primary care, Cuba's model is a comprehensive public health approach that meets the World Health Organization's definition of primary care. The history of the development of Cuba's model is presented, including an update on the innovative neighborhood/home clinics. Achievements in health outcomes as a result of Cuba's model and the consequences for women's health care are discussed. Examples are presented of the effects on health care delivery of the economic hardship that Cuba has experienced since 1991 as a result of the loss of 85% of its trade with the former Soviet Union and the intensified U.S. embargo. A critique of Cuba's model concludes the article.
Hine, Jeffrey F; Grennan, Allison Q; Menousek, Kathryn M; Robertson, Gail; Valleley, Rachel J; Evans, Joseph H
As the benefits of integrated behavioral health care services are becoming more widely recognized, this study investigated physician satisfaction with ongoing integrated psychology services in pediatric primary care clinics. Data were collected across 5 urban and 6 rural clinics and demonstrated the specific factors that physicians view as assets to having efficient access to a pediatric behavioral health practitioner. Results indicated significant satisfaction related to quality and continuity of care and improved access to services. Such models of care may increase access to care and reduce other service barriers encountered by individuals and their families with behavioral health concerns (ie, those who otherwise would seek services through referrals to traditional tertiary care facilities).
Carlfjord, Siw; Johansson, Kjell; Bendtsen, Preben; Nilsen, Per; Andersson, Agneta
Objective: The aim of this study was to evaluate staff experiences of the use of a computer-based concept for lifestyle testing and tailored advice implemented in routine primary health care (PHC). Design: The design of the study was a cross-sectional, retrospective survey. Setting: The study population consisted of staff at nine PHC units in the…
Riddle, Mark A; dosReis, Susan; Reeves, Gloria M; Wissow, Lawrence S; Pruitt, David B; Foy, Jane Meschan
In a 2009 policy statement focused on children's mental health, the American Academy of Pediatrics recommended that pediatric primary care physicians achieve competence in initiating care for children with attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, and substance use/abuse. Because treatment for 3 of these conditions--ADHD, anxiety, and depression--may, under certain conditions, include medication, the primary purpose of this article is to offer guidance to assist primary care physicians in decision-making about their use of psychotropic medications for these conditions. A few medications with proven efficacy and safety are emphasized. Secondarily, other medications that may be useful for other disorders are noted.
Bragaglia, Pauline; O'Brien, Lewis
This response to the essay is a "view from the trenches" by two doctors who have worked over 23 years at the Group Health Centre in Sault Ste. Marie, Ontario. We would agree wholeheartedly that reducing wait times for selected procedures will not transform our health system, although they are a start that does provide improved quality of life for a relatively small number of people. We have struggled with the care gap between known best practices and the reality of care provided, from the perspectives of both prevention and chronic disease management. This has resulted in an acute awareness of the need for an across-the-system, "bottom-up" approach to the prevention of disease and management of healthcare. Limited resources must be carefully leveraged in innovative ways if we are to eliminate this care gap, decrease morbidity and minimize expensive "rescue" procedures that make our system increasingly unaffordable.
Studzin´ski, Krzysztof; Tomasik, Tomasz; Krzyszton´, Janusz; Józ´wiak, Jacek; Windak, Adam
Introduction Major clinical practice guidelines recommend assessing risk of cardiovascular disease (CVD) using absolute/global/total CVD risk scores. However, the effectiveness of using them in clinical practice, despite publication of numerous randomised controlled trials (RCTs), is still poorly understood. To summarise and analyse current knowledge in this field, we will carry out an overview of existing systematic reviews (SRs). The objective of this overview will be to assess the effect of using cardiovascular risk scoring in routine risk assessment in primary prevention of CVD compared with standard care. Methods and analysis We will include SRs and meta-analyses which take into account RCTs and quasi-RCTs investigating the effect of using cardiovascular risk scoring in routine risk assessment in primary prevention of CVD. SRs will be retrieved from 4 bibliographical databases and reference lists of identified reviews. Additionally, the PROSPERO database will be searched for unpublished, ongoing or recently completed SRs. 2 reviewers will assess the SRs independently for eligibility and bias. The data will be extracted to a special form. Any disagreement will be resolved by discussion. In case of lack of consensus, a third author will arbitrate. The overview of SRs will be reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. Ethics and dissemination Ethics approval is not required for overview of SRs. We will summarise evidence concerning whether use of the absolute/global/total CVD risk scoring tools in primary prevention of CVD is effective and supported with scientific data or not. If we face unsatisfactory confirmation, we will highlight a need for further research and advice on how to plan such a study. We will submit the results of our study for peer-review publication in a journal indexed in the international bibliographic database of biomedical information. PMID:28274967
Baron, Richard J.
Those in practice find that the fee-for-service system does not adequately value the contributions made by primary care. The Center for Medicare and Medicaid Innovation (Innovation Center) was created by the Affordable Care Act to test new models of health care delivery to improve the quality of care while lowering costs. All programs coming out of the Innovation Center are tests of new payment and service delivery models. By changing both payment and delivery models and moving to a payment model that rewards physicians for quality of care instead of volume of care, we may be able to achieve the kind of health care patients want to receive and primary care physicians want to provide. PMID:22412007
... Revision, Clinical Modification (ICD-9-CM) ( 10 ) diagnosis code of V22 (supervision of normal pregnancy) or V23 ( ... high-risk pregnancy) or a reason for visit code of 3205.0 (prenatal examination, routine) ( 11 â ...
Rocha, Thiago Augusto Hernandes; da Silva, Núbia Cristina; Thomaz, Erika Bárbara Abreu Fonseca; Queiroz, Rejane Christine de Sousa; de Souza, Marta Rovery; Lein, Adriana; Alvares, Viviane; de Almeida, Dante Grapiuna; Barbosa, Allan Claudius Queiroz; Thumé, Elaine; Staton, Catherine; Vissoci, João Ricardo Nickenig; Facchini, Luiz Augusto
Cervical cancer is a common neoplasm that is responsible for nearly 230 000 deaths annually in Brazil. Despite this burden, cervical cancer is considered preventable with appropriate care. We conducted a longitudinal ecological study from 2002 to 2012 to examine the relationship between the delivery of preventive primary care and cervical cancer mortality rates in Brazil. Brazilian states and the federal district were the unit of analysis (N = 27). Results suggest that primary health care has contributed to reducing cervical cancer mortality rates in Brazil; however, the full potential of preventive care has yet to be realized. PMID:28252500
Nicholson, Caroline; Jackson, Claire L; Marley, John E; Wells, Robert
Primary health care in Australia has undergone 2 decades of change. Starting with a vision for a national health strategy with general practice at its core, Australia established local meso-level primary health care organizations--Divisions of General Practice--moving from focus on individual practitioners to a professional collective local voice. The article identifies how these meso-level organizations have helped the Australian primary health care system evolve by supporting the roll-out of initiatives including national practice accreditation, a focus on quality improvement, expansion of multidisciplinary teams into general practice, regional integration, information technology adoption, and improved access to care. Nevertheless, there are still challenges to ensuring equitable access and the supply and distribution of a primary care workforce, addressing the increasing rates of chronic disease and obesity, and overcoming the fragmentation of funding and accountability in the Australian system.
Hansen, Erik N; Adeli, Bahar; Kenyon, Robert; Parvizi, Javad
Antibiotic-laden bone cement (ALBC) is used in primary arthroplasties throughout Europe. In North America, ALBC is only FDA approved for revision arthroplasty after periprosthetic joint infection (PJI). No article has evaluated whether infecting microbial profile and resistance has changed with the introduction of ALBC. We hypothesized that prophylactic use of ALBC in primary total knee arthroplasty (TKA) has not had a significant impact on infecting pathogens, and antibiotic resistance profiles. A retrospective cohort analysis was conducted of all PJI patients undergoing primary TKA and total hip arthroplasty (THA) between January 2000 and January 2009. No significant change in the patterns of infecting PJI pathogens, and no notable increase in percentage resistance was found among organisms grown from patients with PJI that had received prophylactic antibiotic-loaded cement in their primary joint arthroplasty. Early findings suggest that routine prophylactic use of ALBC has not led to changes in infecting pathogen profile, nor has led to the emergence of antimicrobial resistance at our institution.
Miller, William L.; Crabtree, Benjamin F.; Nutting, Paul A.; Stange, Kurt C.; Jaén, Carlos Roberto
PURPOSE Numerous primary care practice development efforts, many related to the patient-centered medical home (PCMH), are emerging across the United States with few guides available to inform them. This article presents a relationship-centered practice development approach to understand practice and to aid in fostering practice development to advance key attributes of primary care that include access to first-contact care, comprehensive care, coordination of care, and a personal relationship over time. METHODS Informed by complexity theory and relational theories of organizational learning, we built on discoveries from the American Academy of Family Physicians’ National Demonstration Project (NDP) and 15 years of research to understand and improve primary care practice. RESULTS Primary care practices can fruitfully be understood as complex adaptive systems consisting of a core (a practice’s key resources, organizational structure, and functional processes), adaptive reserve (practice features that enhance resilience, such as relationships), and attentiveness to the local environment. The effectiveness of these attributes represents the practice’s internal capability. With adequate motivation, healthy, thriving practices advance along a pathway of slow, continuous developmental change with occasional rapid periods of transformation as they evolve better fits with their environment. Practice development is enhanced through systematically using strategies that involve setting direction and boundaries, implementing sensing systems, focusing on creative tensions, and fostering learning conversations. CONCLUSIONS Successful practice development begins with changes that strengthen practices’ core, build adaptive reserve, and expand attentiveness to the local environment. Development progresses toward transformation through enhancing primary care attributes. PMID:20530396
Hofer, Adam N; Abraham, Jean Marie; Moscovice, Ira
Context: Provisions of the Patient Protection and Affordable Care Act of 2010 (PPACA) expand Medicaid to all individuals in families earning less than 133 percent of the federal poverty level (FPL) and make available subsidies to uninsured lower-income Americans (133 to 400 percent of FPL) without access to employer-based coverage to purchase insurance in new exchanges. Since primary care physicians typically serve as the point of entry into the health care delivery system, an adequate supply of them is critical to meeting the anticipated increase in demand for medical care resulting from the expansion of coverage. This article provides state-level estimates of the anticipated increases in primary care utilization given the PPACA's provisions for expanded coverage. Methods: Using the Medical Expenditure Panel Survey, this article estimates a multivariate regression model of annual primary care utilization. Using the model estimates and state-level information regarding the number of uninsured, it predicts, by state, the change in primary care visits expected from the expanded coverage. Finally, the article predicts the number of primary care physicians needed to accommodate this change in utilization. Findings: This expanded coverage is predicted to increase by 2019 the number of annual primary care visits between 15.07 million and 24.26 million. Assuming stable levels of physicians’ productivity, between 4,307 and 6,940 additional primary care physicians would be needed to accommodate this increase. Conclusions: The PPACA's health insurance expansion parameters are expected to significantly increase the use of primary care. Two strategies that policymakers may consider are creating stronger financial incentives to attract medical school students to primary care and changing the delivery of care in ways that lead to operational improvements, higher throughput, and better quality of care. PMID:21418313
Cubic, Barbara; Mance, Janette; Turgesen, Jeri N; Lamanna, Jennifer D
Rapidly occurring changes in the healthcare arena mean time is of the essence for psychology to formalize a strategic plan for training in primary care settings. The current article articulates factors affecting models of integrated care in Academic Health Centers (AHCs) and describes ways to identify and utilize resources at AHCs to develop interprofessional educational and clinical integrated care opportunities. The paper asserts that interprofessional educational experiences between psychology and other healthcare providers are vital to insure professionals value one another's disciplines in health care reform endeavors, most notably the patient-centered initiatives. The paper highlights ways to create shared values and common goals between primary care providers and psychologists, which are needed for trainee internalization of integrated care precepts. A developmental perspective to training from pre-doctoral, internship and postdoctoral levels for psychologists in integrated care is described. Lastly, a call to action is given for the field to develop more opportunities for psychology trainees to receive education and training within practica, internships and postdoctoral fellowships in primary care settings to address the reality that most patients seek their mental health treatment in primary care settings.
Armstrong, Brent; Levesque, Odette; Perlin, Jonathan B; Rick, Cathy; Schectman, Gordon
Can we improve access in primary care without compromising the quality of care? The purpose of this article is to demonstrate how timely access to primary care can be achieved without compromising the quality of the care being delivered. The Veterans Health Administration (VHA) is an integrated healthcare system that has implemented change to improve primary care access to the veterans it serves, while not only maintaining but also actually improving the quality of care. Many healthcare executives are struggling with achieving desirable access to care and continuity of care. To confront this problem, many large and small practices have initiated an approach known as advanced clinic access, open access, or same-day scheduling, introduced by the Institute for Healthcare Improvement (IHI). This approach has increasingly been used to reduce waits and delays in primary care without adding resources. To measure quality of care, specific performance measures were developed to quantify the effectiveness of primary care in VHA. Although it was initially viewed with concern and suspicion and was seen as a symptom of unnecessary micromanagement, healthcare team members were encouraged to use performance feedback as an opportunity for systems improvement as well as self-assessment and performance improvement for the team. All quality data are posted quarterly on VHA's internal web site, providing visible accountability at all levels of the organization. Clinical workflow redesign leads to reduced wait times without compromising quality of care. These large system improvements are applicable to large and small organizations looking to tackle change through the use of a collaborative model.
Taylor, Erin Fries; Machta, Rachel M; Meyers, David S; Genevro, Janice; Peikes, Deborah N
Efforts to redesign primary care require multiple supports. Two potential members of the primary care team-practice facilitator and care manager-can play important but distinct roles in redesigning and improving care delivery. Facilitators, also known as quality improvement coaches, assist practices with coordinating their quality improvement activities and help build capacity for those activities-reflecting a systems-level approach to improving quality, safety, and implementation of evidence-based practices. Care managers provide direct patient care by coordinating care and helping patients navigate the system, improving access for patients, and communicating across the care team. These complementary roles aim to help primary care practices deliver coordinated, accessible, comprehensive, and patient-centered care.
Saul, Robert A
A colloquium on genetic literacy in pediatric primary care sponsored by the Health Resources and Services Administration Maternal and Child Health Bureau was held at the American Academy of Pediatrics headquarters on October 2-3, 2012. The overarching goal of the colloquium was to provide context for delivery of genetics-related services in day-to-day pediatric primary care practice, encompassing 3 dimensions of medicine: prevention, diagnosis, and management. Participants considered the whole spectrum of disease, from rare disorders to common disorders, the genetics-related components of which are often overlooked. Specific topics included family history, genomics, genetic literacy and competency, epigenetics, and a focused view of primary care and genetics. A consensus statement was developed to provide recommendations for integration of genetics into pediatric primary care.
Contracts for nearly 400 primary care services worth £250 million are out to tender as part of the 'biggest single act of privatisation the NHS has ever seen', Labour's health spokesperson Andy Burnham has revealed.
Joo, Min J; Sharp, Lisa K; Au, David H; Lee, Todd A; Fitzgibbon, Marian L
Guidelines that recommend spirometry to confirm airflow obstruction among patients with suspected COPD are not routinely followed. We conducted a qualitative study to identify attitudes and barriers of primary care physicians to performing spirometry for patients with possible COPD. We conducted four focus groups, each with three primary care physicians (PCPs) who practice in an urban, academic medical center. In general, PCPs believed that spirometry was not necessary to confirm the diagnosis of COPD. Compared to other co-morbid conditions, in a patient with a diagnosis of COPD without self-reported symptoms, COPD was not a priority during a clinic visit. This was in part due to the belief that there was lack of evidence that medication used in COPD lead to improved outcomes and that there was no point of care measure for COPD compared to other co-morbid conditions such as diabetes mellitus or hypertension. Health system barriers specific to spirometry use was not identified. In conclusion, in our sample of PCPs, there was skepticism that spirometry is warranted to diagnose and manage COPD. Availability of spirometry was not a perceived barrier. Our results explain, in part, why previous interventions to improve access to spirometry and diagnosis of COPD in primary care settings have been difficult to conduct and/or have had marginal success. Our findings strongly suggest that a first step toward increasing the use of spirometry among primary care physicians is to have them believe in its utility in the diagnosis of COPD.
Staub, Charles L H
The author gives his perspective on the challenges that medical practices will face over the next ten years. Systems of health-care delivery within the practice setting will have to accommodate to a more complex medical agenda, a trend to earlier diagnosis and intervention, and the need to preserve the patient-doctor relationship. In facing these challenges, physicians will need to accept leadership responsibility and be prepared to engage in a more organized, collective approach if we hope to come up with pragmatic solutions that truly work in practice. The guiding principle in all of these changes must be the actual improvement of patient care.
Becker, Werner J.; Findlay, Ted; Moga, Carmen; Scott, N. Ann; Harstall, Christa; Taenzer, Paul
Abstract Objective To increase the use of evidence-informed approaches to diagnosis, investigation, and treatment of headache for patients in primary care. Quality of evidence A comprehensive search was conducted for relevant guidelines and systematic reviews published between January 2000 and May 2011. The guidelines were critically appraised using the AGREE (Appraisal of Guidelines for Research and Evaluation) tool, and the 6 highest-quality guidelines were used as seed guidelines for the guideline adaptation process. Main message A multidisciplinary guideline development group of primary care providers and other specialists crafted 91 specific recommendations using a consensus process. The recommendations cover diagnosis, investigation, and management of migraine, tension-type, medication-overuse, and cluster headache. Conclusion A clinical practice guideline for the Canadian health care context was created using a guideline adaptation process to assist multidisciplinary primary care practitioners in providing evidence-informed care for patients with headache. PMID:26273080
Goldberg, Debora Goetz; Beeson, Tishra; Kuzel, Anton J; Love, Linda E; Carver, Mary C
The purpose of this study was to gain an in-depth understanding of how primary care practices in the United States are transforming their practice to deliver patient-centered care. The study used qualitative research methods to conduct case studies of small primary care practices in the state of Virginia. The research team collected data from practices using in-depth interviews, structured telephone questionnaires, observation, and document review. Team-based care stood out as the most critical method used to successfully transform practices to provide patient-centered care. This article presents 3 team-based care models that were utilized by the practices in this study.
Beasley, John W; Karsh, Ben-Tzion; Stone, Jamie A; Smith, Paul D; Wetterneck, Tosha B
Objective Primary care efficiency and quality are essential for the nation’s health. The demands on primary care physicians (PCPs) are increasing as healthcare becomes more complex. A more complete understanding of PCP workflow variation is needed to guide future healthcare redesigns. Methods This analysis evaluates workflow variation in terms of the sequence of tasks performed during patient visits. Two patient visits from 10 PCPs from 10 different United States Midwestern primary care clinics were analyzed to determine physician workflow. Tasks and the progressive sequence of those tasks were observed, documented, and coded by task category using a PCP task list. Variations in the sequence and prevalence of tasks at each stage of the primary care visit were assessed considering the physician, the patient, the visit’s progression, and the presence of an electronic health record (EHR) at the clinic. Results PCP workflow during patient visits varies significantly, even for an individual physician, with no single or even common workflow pattern being present. The prevalence of specific tasks shifts significantly as primary care visits progress to their conclusion but, notably, PCPs collect patient information throughout the visit. Discussion PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a “dance” between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice. Conclusions Future healthcare redesigns should support a wide variety of task sequences to deliver high-quality primary care. The development of tools such as electronic health records must be based on the realities of primary care visits if they are to successfully support a PCP’s mental and physical work, resulting in effective, safe, and efficient primary care. PMID:26335987
Jacobson, Lionel; Elwyn, Glyn; Robling, Michael; Jones, Rhiannedd Tudor
This paper examines the notions of adverse events, error, critical incidents and safety from the specific viewpoint of primary care. We conclude that each term can be defined, but existing work which we reviewed uses many of the terms interchangeably. We recognise that trying to access medical error objectively within primary care can be problematic. Regardless of definitions, reflection on critical incidents, adverse events or other notable events is important, but requires time and resources to be conducted effectively.
Baird, G; Hall, D M
There is little agreement about what constitutes good developmental paediatric practice at the level of primary care. Many of the available screening tests are intrinsically unsatisfactory or badly performed, but screening is only a small part of developmental paediatrics. Every primary care doctor should be familiar with the scientific basis of the subject even if a decision is made not to embark on a formal screening programme. PMID:2412629
CarolinaApesoa-Varano, Ester; Barker, Judith C.; Hinton, Ladson
The symbolic framework guiding primary care physicians’ (PCPs) practice is crucial in shaping the quality of care for those with degenerative dementia. Examining the relationship between the cure and care models in primary care offers a unique opportunity for exploring change toward a more holistic approach to health care. The aims of this study were to (a) explore how PCPs approach the care of patients with Alzheimer’s disease (AD), and (b) describe how this care unfolds from the physicians’ perspectives. This was a cross-sectional study of 40 PCPs who completed semistructured interviews as part of a dementia caregiving study. Findings show that PCPs recognize the limits of the cure paradigm and articulate a caring, more holistic model that addresses the psychosocial needs of dementia patients. However, caring is difficult to uphold because of time constraints, emotional burden, and jurisdictional issues. Thus, the care model remains secondary and temporary. PMID:21685311
Davis, Melinda M.; Bond, Lynne A.; Howard, Alan; Sarkisian, Catherine A.
Purpose: Expectations regarding aging (ERA) in community-dwelling older adults are associated with personal health behaviors and health resource usage. Clinicians' age expectations likely influence patients' expectations and care delivery patterns; yet, limited research has explored clinicians' age expectations. The Expectations Regarding Aging…
González-de Paz, L
The clinical decision making process with ethical implications in the area of primary healthcare differs from other healthcare areas. From the ethical perspective it is important to include these issues in the decision making model. This dissertation explains the need for a process of bioethical deliberation for Primary Healthcare, as well as proposing a method for doing so. The decision process method, adapted to this healthcare area, is flexible and requires a more participative Healthcare System. This proposal involves professionals and the patient population equally, is intended to facilitate the acquisition of responsibility for personal and community health.
Although less focused upon given the current emphasis on the patient-centered medical home innovation, the future for US primary care is arguably one that will be characterized by diversity in service delivery structures and personnel. The drivers of this diversity include increased patient demand requiring a larger number of primary care access points; the need for lower-cost delivery structures that can flourish in a low-margin business model; greater interest in primary care delivery by retailers and hospitals that see their involvement as a means to enhance their core business goals; the increased desire by non-physician providers to gain work independence; and a growing cadre of younger PCPs whose career and job preferences leave them open to working in a variety of different settings and structures. A key issue to ask of a more diversified primary care system is whether or not it will be characterized by competition or cooperation. While a competitive system would not be unexpected given historical and current trends, such a system would likely stunt the prospects for a full revitalization of US primary care. However, there is reason to believe that a cooperative system is possible and would be advantageous, given the mutual dependencies that already exist among primary care stakeholders, and additional steps that could be taken to enhance such dependencies even more into the future.
Reiter, Jeff; Runyan, Christine
Primary care settings are particularly prone to complex relationships that can be ethically challenging. This is due in part to three of the distinctive attributes of primary care: a whole family orientation; team-based care; and a longitudinal care delivery model. In addition, the high patient volume of primary care means that the likelihood of encountering ethically challenging relationships is probably greater than in a specialty setting. This article argues that one ethical standard of the American Psychological Association (APA, 2010, Ethical principles of psychologists and code of conduct, www.apa.org/ethics/code) (10.02, Therapy Involving Couples or Families) should be revised to better accommodate the work of psychologists in primary care. The corresponding Principles of Medical Ethics from the American Medical Association (AMA, 2012, Code of medical ethics: Current opinions with annotations, 2012-2013, Washington, DC: Author), most notably the principle regarding a physician's duty to "respect the rights of patients, colleagues, and other health professionals as well as safeguard privacy" are also noted. In addition, the article details how the three attributes of primary care often result in complex relationships, and provides suggestions for handling such relationships ethically.
Rahimzadeh, Vasiliki; Bartlett, Gillian
Since first sequencing the human genome in 2003, emerging genetic/genomic technologies have ushered in a revolutionary era of medicine that purports to bridge molecular biology and clinical care. The field of translational medicine is charged with mediating this revolution. Sequencing innovations are far outpacing guidelines intended to ease their practice-based applications, including in primary care. As a result, genomic medicine's full integration in primary care settings especially, has been slow to materialize. Researchers and clinicians alike face substantial challenges in navigating contentious ethical issues raised in translation and implementation, namely preserving the spirit of whole-person approaches to care; maintaining respect for persons and communities; and translating genetic risk into clinical actionability. This commentary therefore explores practical barriers to, and ethical implications of, incorporating genomic technologies in the primary care sector. These ethical challenges are both philosophical and infrastructural. From a primary care perspective, the commentary further reviews the ethical, legal and social implications of the Center for Disease Control's proposed model for assessing the validity and utility of genomic testing and family health history applications. Lastly, the authors provide recommendations for future translational initiatives that aim to maximize the capacities of genomic medicine, without compromising primary care philosophies and foundations of practice.
Bower, Peter; Jerrim, Sophie; Gask, Linda
A number of professionals are involved in mental health in primary care. The NHS Plan proposed the introduction of a new professional, the primary care mental health worker (PCMHW), to improve care in this setting. The present study was conducted to examine pilot PCMHW-type roles currently in existence, to explore staff expectations concerning the new PCMHW role and to consider the issues relating to roles in primary care mental health that are raised by this new worker. The study used a case study design, and involved qualitative interviews with 46 managers and clinicians from primary care and specialist mental health services, including pilot PCMHW-type roles. The key findings were as follows: The pilot PCMHW-type roles were almost exclusively related to client work, whereas respondents had far wider role expectations of the new PCMHWs, relating to perceived gaps in current service provision. This highlights the potential for role conflict. Secondly, there was disagreement and ambiguity among some respondents as to the nature of the new PCMHW's role in client work, and its relationship with the work undertaken by other mental health professionals such as counsellors, psychologists and nurses. Given that multiple professionals are involved in mental health care in primary care, issues relating to roles are likely to be crucial in the effective implementation of the new PCMHWs.
Yip, Amelia; Leduc, Matthew; Teo, Vincent; Timmons, Matthew; Schull, Michael J
The objective was to develop and validate a method to link routinely captured electronic data for the measurement of emergency department (ED) quality indicators. Electronic ED data were linked to calculate time to antibiotics and time to electrocardiogram (ECG) for pneumonia and chest pain patients, respectively; validation was by comparison with chart data. Linked electronic data correctly identified 40/40 pneumonia and 65/65 chest pain patients. The median difference in time to antibiotics calculated from linked electronic data versus chart data was 6 minutes (standard deviation [SD] = 14.0); for time to ECG it was 0 minutes (SD = 70). The percentage of ED patients meeting target time to antibiotics was 47% with electronic data versus 44% with charts; for time to ECG, 8% met target time with electronic data versus 11% with charts. A simple computer algorithm for linking routine ED electronic data for quality-of-care measurement was validated.
Schraiber, Lilia Blima; Figueiredo, Wagner dos Santos; Gomes, Romeu; Couto, Márcia Thereza; Pinheiro, Thiago Félix; Machin, Rosana; Silva, Geórgia Sibele Nogueira da; Valença, Otávio
This study deals with the relations between masculinities and health care, approaching the recognition of health needs among male users of primary health care and the responses by the services. The study is part of a larger research project in four Brazilian States, with a convenience sample of eight health services. Ethnographic observation was compared with semi-structured interviews with 182 health care users from 15 to 65 years of age and 72 health professionals. Thematic analysis of the ethnographic records and interviews was based on gender references and studies on health work. The findings show how medicalization of health needs affects users, professionals, and services, disguising issues related to masculinity. Primary care focuses mainly on women, thereby reproducing gender inequalities in health services operations and professional performance, with women receiving disciplined care and men receiving insufficient attention and care.
Hails, Katherine; Brill, Charlotte D; Chang, Trina; Yeung, Albert; Fava, Maurizio; Trinh, Nhi-Ha
Major depressive disorder (MDD) is a prevalent illness in minority populations. Minority patients with MDD are often unrecognized and untreated. This review examines promising interventions to address MDD in primary care settings, where minority groups are more likely to seek care. Since 2010, eleven interventions have been developed to address patient-specific and provider-specific barriers, many of which are adaptations of the collaborative care model. Other promising interventions include cultural tailoring of the collaborative care model, as well as the addition of telepsychiatry, motivational interviewing, cultural consultation, and innovations in interpreting. Overall, collaborative care was found feasible and improved satisfaction and treatment engagement of depressed minority patients in primary care. It remains inconclusive whether these newer intervention models improve MDD treatment outcomes. Future research will be needed to establish the effectiveness of these intervention models in improving the treatment outcomes of minority populations with MDD.
Ozminkowski, R J; Noether, M; Nathanson, P; Smith, K M; Raney, B E; Mickey, D; Hawley, P M
We developed methods for comparing physicians who would be selected to participate in a major employer's self-insurance program. These methods used insurance claims data to identify and profile physicians according to deviations from prevailing practice and outcome patterns, after considering differences in case-mix and severity of illness among the patients treated by those providers. The discussion notes the usefulness and limitations of claims data for this and other purposes. We also comment on policy implications and the relationships between our methods and health care reform strategies designed to influence overall health care costs.
Ely, Andrea C.; Banitt, Angela; Befort, Christie; Hou, Qing; Rhode, Paula C.; Grund, Chrysanne; Greiner, Allen; Jeffries, Shawn; Ellerbeck, Edward
Context: Obesity is a chronic disease of epidemic proportions in the United States. Primary care providers are critical to timely diagnosis and treatment of obesity, and need better tools to deliver effective obesity care. Purpose: To conduct a pilot randomized trial of a chronic care model (CCM) program for obesity care in rural Kansas primary…
Lima, Bruno R.
This paper focuses on the mental health consequences of the disaster in Armero, Colombia which resulted from a volcanic eruption and mudslide, and highlights the role of the primary care worker in delivering mental health care to disaster victims. Eight characteristics of disasters that are closely related to their psychopathogenetic potential…
Green, Elizabeth; Larcombe, J; Horbury, I
The health of teenagers is currently a priority of the NHS, with many schemes and projects being developed. There are documented difficulties for teenagers in accessing health care, especially within general practice. This article describes the development and evaluation of a tailor-made clinic in the primary care setting.
DeFriese, G H; Ricketts, T C
The confluence of forces slowing the growth of the physician supply despite a continued shortage of primary care physicians, the encouragement of competitive medical practices that centralize resources in larger places, and the changing of the rural population's character to one of more dependence on medical care may bring on another "rural health crisis" in the decade ahead. PMID:2645252
Solberg, Leif I; Elward, Kurtis S; Phillips, William R; Gill, James M; Swanson, Graham; Main, Deborah S; Yawn, Barbara P; Mold, James W; Phillips, Robert L
The chasm between knowledge and practice decried by the Institute of Medicine (IOM) is the result of other chasms that have not been addressed. They include the chasm between what we know and what we need to know to improve care; the chasm between those who provide primary care and those who do not fund, study, support, or publish practical primary care studies; and the chasm between research and quality improvement (QI). These chasms are a result of problematic concepts, attitudes, traditions, time frames, and financing approaches among the various participants. If we are to facilitate the production and use of the knowledge needed for primary care to cross IOM's chasm, major changes are needed. These changes include the following: (1) admission by all primary care professions that we have quality problems that require our unified attention and action; (2) conversion of the paradigm from "translate research into practice" to "optimizing health and health care through research and QI"; (3) development and facilitation of more partnerships among clinicians, researchers, and care delivery leaders for engaged scholarship in both research and QI; (4) modification of the agendas and methods of funders and researchers so they emphasize the problems of patients and patient care and support practical time frames and research designs; and (5) facilitation by funders and journals of the dissemination and implementation of lessons from QI and practical research.
McCune, Renee L.
Patient health literacy skills are critical to effective healthcare communication and safe care delivery in primary care settings. Methods and strategies to identify patient health literacy (HL) capabilities and provider/staff knowledge, attitudes and beliefs (KAB) regarding HL must be known before addressing provider/staff communication skills.…
Willig, James H.; Rodgers, Joel B.; Donnelly, John P.; Westfall, Andrew O.; Ross-Davis, Kelly L.; Heath, Sonya L.
Objective The Centers for Disease Control and Prevention has recommended emergency department (ED) opt-out HIV screening since 2006. Routine screening can prove challenging due to the ED's complexity and competing priorities. This study examined the implementation and evolution of a routine, integrated, opt-out HIV screening program at an urban academic ED in Alabama since August 2011. Methods ED routine, opt-out HIV screening was implemented as a standard of care in September 2011. To describe the outcomes and escalation of the screening program, data analyses were performed from three separate data queries: (1) encounter-level HIV screening questionnaire and test results from September 21, 2011, through December 31, 2013; (2) test-level, fourth-generation HIV results from July 9 through December 31, 2013; and (3) daily HIV testing rates and trends from September 9, 2011, through June 30, 2014. Results Of the 46,385 HIV screening tests performed, 252 (0.5%) were confirmed to be positive. Acute HIV infection accounted for 11.8% of all HIV patients identified using the fourth-generation HIV screening assay. Seventy-six percent of confirmed HIV-positive patients had successful linkage to care. Implementation of fourth-generation HIV instrument-based testing resulted in a 15.0% decline in weekly HIV testing rates. Displacement of nursing provider HIV test offers from triage to the bedside resulted in a 31.6% decline in weekly HIV testing rates. Conclusion This program demonstrated the capacity for high-volume, routine, opt-out HIV screening. Evolving ED challenges require program monitoring and adaptation to sustain scalable HIV screening in EDs. PMID:26862235
Betz, Marian E.; Jones, Jacqueline; Carr, David B.
Background Primary care physicians play a leading role in counseling older drivers, but discussions often do not occur until safety concerns arise. Prior work suggests that routine questioning about driving might facilitate these difficult conversations. Objective To explore system-level factors affecting driving discussions in primary care settings, in order to inform the design and implementation of a program supporting routine conversations. Methods This qualitative descriptive study used iterative interviews with providers (physicians, nurses, medical assistants, social workers, and administrative staff) working at two clinics (one geriatric, one general internal medicine) at a tertiary-care teaching hospital. General inductive techniques in transcript analysis were used to identify stakeholder-perceived system-level barriers and facilitators to routine conversations with older drivers. Results From fifteen interviews, four themes emerged: (1) complexity of defined provider roles within primary care setting (which can both support team work and hamper efficiency); (2) inadequate resources to support providers (including clinical prompts, local guides, and access to social workers and driving specialists); (3) gaps in education of providers and patients about discussing driving; and (4) suggested models to enhance provider conversations with older drivers (including following successful examples and using defined pathways integrated into the electronic medical record). A fifth theme was that participants characterized their experiences in terms of current and ideal states. Conclusions Physicians have been tasked with assessing older driver safety and guiding older patients through the process of “driving retirement.” Attention to system-level factors such as provider roles, resources, and training can support them in this process. PMID:25617342
Edbrooke-Childs, Julian; Newman, Robbie; Fleming, Isobel; Deighton, Jessica; Wolpert, Miranda
Adults from black and minority ethnic (BAME) backgrounds are less likely to access mental health services through voluntary care pathways and are more likely to access through compulsory ones. The aim of the present research was to explore the association between ethnicity and care pathway through child and adolescent mental health services (CAMHS), in terms of reason for referral and case closure, in children presenting with emotional problems. A sample of N = 11,592 children from 26 CAMHS was taken from a national routinely collected dataset (56 % female; 7 % aged 0-5 years, 40 % 6-12 years, 53 % 13-18 years, and <1 % 19-25 years). Multinomial logistic regressions showed that BAME children were consistently more likely to be referred to CAMHS through education, social, and other services than primary care, compared to White British children (odds ratio (OR) = 1.52-9.96, p < .001) and they were less likely to end treatment due to child and family non-attendance (OR = 0.59-0.79, p < .05). Similar to adults, children from BAME groups may be more likely to access CAMHS through compulsory than voluntary care pathways.
Tan, Ngiap Chuan
Singapore is facing an increasing noncommunicable disease burden due to its ageing population. Singapore’s primary healthcare services, provided by both polyclinic physicians and private general practitioners, are available to the public at differential fees for service. The resultant disproportionate patient loads lead to dissatisfaction for both healthcare providers and consumers. This article describes the ‘PAIR UP’ approach as a potential endeavour to facilitate primary care physicians (PCPs) in public and private sectors to collaborate to deliver enhanced primary care in Singapore. PAIR UP is an acronym referring to Policy, Academic development, Integration of healthcare information system, Research in primary care, Utility and safety evaluation, and Practice transformation. The current healthcare landscape is favourable to test out this multipronged approach. PCPs in both sectors can ride on it and work together synergistically to provide quality primary care in Singapore. PMID:24664374
Hefner, Jennifer L; Wexler, Randy; McAlearney, Ann Scheck
The objective was to explore variation by insurance status in patient-reported barriers to accessing primary care. The authors fielded a brief, anonymous, voluntary survey of nonurgent emergency department (ED) visits at a large academic medical center and conducted descriptive analysis and thematic coding of 349 open-ended survey responses. The privately insured predominantly reported primary care infrastructure barriers-wait time in clinic and for an appointment, constraints related to conventional business hours, and difficulty finding a primary care provider (because of geography or lack of new patient openings). Half of those insured by Medicaid and/or Medicare also reported these infrastructure barriers. In contrast, the uninsured predominantly reported insurance, income, and transportation barriers. Given that insured nonurgent ED users frequently report infrastructure barriers, these should be the focus of patient-level interventions to reduce nonurgent ED use and of health system-level policies to enhance the capacity of the US primary care infrastructure.
This article discusses the current nature of primary teachers' work, which is explored in terms of "performing" and "caring" activities. It considers how the education policies of successive Governments in the UK, particularly for England, have given rise to a "performance culture" in primary schools which emphasises…
Strain, James J.; And Others
The characteristics of the mental health components of residency training in traditional internal medicine, primary care internal medicine, and family practice were examined. Internal medicine programs relied on the consultation method and in-patient facilities, and used the psychiatrist as the primary teacher. Evaluation of the outcome of…
Blendon, R J; Szalay, U S; Altman, D E; Chervinsky, G
Voters in the June 2 last-in-the-nation California primary indicated that candidates' character, experience, and leadership ability have become more significant than their stands on such issues as health reform. However, among substantive campaign issues, health care ranked second, behind the economy. That is consistent with previous poll results from New Hampshire, the nation's first primary state.
Goldstein, Ellen; Athale, Ninad; Sciolla, Andrés F; Catz, Sheryl L
Context: Exposure to traumatic events is common in primary care patients, yet health care professionals may be hesitant to assess and address the impact of childhood trauma in their patients. Objective: To assess patient preferences for discussing traumatic experiences and posttraumatic stress disorder (PTSD) with clinicians in underserved, predominantly Latino primary care patients. Design: Cross-sectional study. Main Outcome Measure: We evaluated patients with a questionnaire assessing comfort to discuss trauma exposure and symptoms using the Adverse Childhood Experiences (ACE) Study questionnaire and the Primary Care-PTSD screen. The questionnaire also assessed patients’ confidence in their clinicians’ ability to help with trauma-related issues. Surveys were collected at an integrated medical and behavioral health care clinic. Results: Of 178 adult patients asked, 152 (83%) agreed to participate. Among participants, 37% screened positive for PTSD, 42% reported 4 or more ACEs, and 26% had elevated scores on both measures. Primary Care-PTSD and ACE scores were strongly positively correlated (r = 0.57, p < 0.001). Most patients agreed they were comfortable being asked about trauma directly or through screening questionnaires and did not oppose the inclusion of trauma-related information in their medical record. In addition, most patients perceived their clinician as comfortable asking questions about childhood trauma and able to address trauma-related problems. Conclusion: Screening is acceptable to most primary care patients regardless of trauma exposure or positive PTSD screening. Findings may aid primary care clinicians to consider screening regularly for ACEs and PTSD to better serve the health care needs of trauma-exposed patients. PMID:28333604
Power, Thomas J.; Blum, Nathan J.; Guevara, James P.; Jones, Heather A.; Leslie, Laurel K.
Although primary care practices and schools are major venues for the delivery of mental health services to children, these systems are disconnected, contributing to fragmentation in service delivery. This paper describes barriers to collaboration across the primary care and school systems, including administrative and fiscal pressures, conceptual…
Pidano, Anne E.; Honigfeld, Lisa; Bar-Halpern, Miri; Vivian, James E.
Background: As many as 20 % of children have diagnosable mental health conditions and nearly all of them receive pediatric primary health care. However, most children with serious mental health concerns do not receive mental health services. This study tested hypotheses that pediatric primary care providers (PPCPs) in relationships with mental…
Kuo, Grace M; Hawley, Sarah T; Weiss, L Todd; Balkrishnan, Rajesh; Volk, Robert J
Background The use of herbal supplements in the United States has become increasingly popular. The prevalence of herbal use among primary care patients varies in previous studies; the pattern of herbal use among urban racially/ethnically diverse primary care patients has not been widely studied. The primary objectives of this study were to describe the use of herbs by ethnically diverse primary care patients in a large metropolitan area and to examine factors associated with such use. The secondary objective was to investigate perceptions about and patterns of herbal use. Methods Data for a cross-sectional survey were collected at primary care practices affiliated with the Southern Primary-care Urban Research Network (SPUR-Net) in Houston, Texas, from September 2002 to March 2003. To participate in the study, patients had to be at least 18 years of age and visiting one of the SPUR-Net clinics for routine, nonacute care. Survey questions were available in both English and Spanish. Results A total of 322 patients who had complete information on race/ethnicity were included in the analysis. Overall, 36% of the surveyed patients (n = 322) indicated use of herbs, with wide variability among ethnic groups: 50% of Hispanics, 50% of Asians, 41% of Whites, and 22% of African-Americans. Significant factors associated with an individual's herbal use were ethnicity other than African-American, having an immigrant family history, and reporting herbal use by other family members. About 40% of survey respondents believed that taking prescription medications and herbal medicines together was more effective than taking either alone. One-third of herbal users reported using herbs on a daily basis. More Whites (67%) disclosed their herbal use to their health-care providers than did African-Americans (45%), Hispanics (31%), or Asians (31%). Conclusions Racial/ethnic differences in herbal use were apparent among this sample of urban multiethnic adult primary care patients. Associated
Morrison, Deborah; Agur, Karolina; Mercer, Stewart; Eiras, Andreia; González-Montalvo, Juan I; Gruffydd-Jones, Kevin
The term multimorbidity is usually defined as the coexistence of two or more chronic conditions within an individual, whereas the term comorbidity traditionally describes patients with an index condition and one or more additional conditions. Multimorbidity of chronic conditions markedly worsens outcomes in patients, increases treatment burden and increases health service costs. Although patients with chronic respiratory disease often have physical comorbidities, they also commonly experience psychological problems such as depression and anxiety. Multimorbidity is associated with increased health-care utilisation and specifically with an increased number of prescription drugs in individuals with multiple chronic conditions such as chronic obstructive pulmonary disease. This npj Primary Care Respiratory Medicine Education Section case study involves a patient in a primary care consultation presenting several common diseases prevalent in people of this age. The patient takes nine different drugs at this moment, one or more pills for each condition, which amounts to polypharmacy. The problems related with polypharmacy recommend that a routine medication review by primary care physicians be performed to reduce the risk of adverse effects of polypharmacy among those with multiple chronic conditions. The primary care physician has the challenging role of integrating all of the clinical problems affecting the patient and reviewing all medicaments (including over-the-counter medications) taken by the patient at any point in time, and has the has the key to prevent the unwanted consequences of polypharmacy. Multimorbid chronic disease management can be achieved with the use of care planning, unified disease templates, use of information technology with appointment reminders and with the help of the wider primary care and community teams. PMID:27629064
Quillian, J P
Community participation and utilization of community health workers (CHWs) are essential components of the primary health care model. The success of CHWs is dependent on their training and subsequent community support. Community-prepared nurses are ideal CHW educators. A training program for CHWs was implemented in Honduras emphasizing the principles of adult learning and problem-based learning. Following a 4-month program of training a primary health care clinic was opened and managed by CHWs for a population over 10,000. Approximately 80% of local health problems were managed by the CHWs proving that well-trained CHWs can have a significant impact on the delivery of health care.
A Randomized Controlled Trial Protocol to Evaluate the Effectiveness of an Integrated Care Management Approach to Improve Adherence Among HIV-Infected Patients in Routine Clinical Care: Rationale and Design
Fredericksen, Rob J; Church, Anna; Harrington, Anna; Ciechanowski, Paul; Magnani, Jennifer; Nasby, Kari; Brown, Tyler; Dhanireddy, Shireesha; Harrington, Robert D; Lober, William B; Simoni, Jane; Safren, Stevan A; Edwards, Todd C; Patrick, Donald L; Saag, Michael S; Crane, Paul K; Kitahata, Mari M
Background Adherence to antiretroviral medications is a key determinant of clinical outcomes. Many adherence intervention trials investigated the effects of time-intensive or costly interventions that are not feasible in most clinical care settings. Objective We set out to evaluate a collaborative care approach as a feasible intervention applicable to patients in clinical care including those with mental illness and/or substance use issues. Methods We developed a randomized controlled trial (RCT) investigating an integrated, clinic-based care management approach to improve clinical outcomes that could be integrated into the clinical care setting. This is based on the routine integration and systematic follow-up of a clinical assessment of patient-reported outcomes targeting adherence, depression, and substance use, and adapts previously developed and tested care management approaches. The primary health coach or care management role is provided by clinic case managers allowing the intervention to be generalized to other human immunodeficiency virus (HIV) clinics that have case managers. We used a stepped-care approach to target interventions to those at greatest need who are most likely to benefit rather than to everyone to maintain feasibility in a busy clinical care setting. Results The National Institutes of Health funded this study and had no role in study design, data collection, or decisions regarding whether or not to submit manuscripts for publication. This trial is currently underway, enrollment was completed in 2015, and follow-up time still accruing. First results are expected to be ready for publication in early 2017. Discussion This paper describes the protocol for an ongoing clinical trial including the design and the rationale for key methodological decisions. There is a need to identify best practices for implementing evidence-based collaborative care models that are effective and feasible in clinical care. Adherence efficacy trials have not led to
Corsetti, Maura; Whorwell, Peter J
The classic symptoms of irritable bowel syndrome (IBS) are abdominal pain, bloating and some form of bowel dysfunction. The pain is typically colicky in nature and can occur at any site although most commonly it is on the left side. The abdomen feels flat in the morning and then gradually becomes more bloated as the day progresses reaching a peak by late afternoon or evening. It then subsides again over night. Traditionally IBS is divided into diarrhoea, constipation or alternating subtypes. IBS patients frequently complain of one or more non-colonic symptoms, these include constant lethargy, low backache, nausea, bladder symptoms suggestive of an irritable bladder, chest pain and dyspareunia in women. The traditional view that IBS is a largely psychological condition is no longer tenable. Rectal bleeding, a family history of malignancy and a short history in IBS should always be treated with suspicion. Both pain and bowel dysfunction are often made worse by eating. It is recommended that a coeliac screening test is undertaken to rule out this condition. Other routine tests should include inflammatory markers such as CRP or ESR. Calprotectin is a marker for leukocytes in the stools and detects gastrointestinal inflammation. A negative test almost certainly rules out inflammatory bowel disease, especially in conjunction with a normal CRP. Fermentable carbohydrates can have a detrimental effect on IBS and this has led to the introduction of the low FODMAP diet.
Stellefson, Michael; Stopka, Christine
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
Delva, Dianne; Jamieson, Margaret; Lemieux, Melissa
Primary health care is undergoing significant organizational change, including the development of interdisciplinary health care teams. Understanding how teams function effectively in primary care will assist training programs in teaching effective interprofessional practices. This study aimed to explore the views of members of primary health care teams regarding what constitutes a team, team effectiveness and the factors that affect team effectiveness in primary care. Focus group consultations from six teams in the Department of Family Medicine at Queen's University were recorded and transcribed and qualitative analysis was used to identify themes. Twelve themes were identified that related to the impact of dual goals/obligations of education and clinical/patient practice on team relationships and learners; the challenges of determining team membership including nonattendance of allied health professionals except nurses; and facilitators and barriers to effective team function. This study provides insight into some of the challenges of developing effective primary care teams in an academic department of family medicine. Clear goals and attention to teamwork at all levels of collaboration is needed if effective interprofessional education is to be achieved. Future research should clarify how best to support the changes required for increasingly effective teamwork.
Taira, Deborah A; Safran, Dana Gelb; Seto, Todd B; Rogers, William H; Kosinski, Mark; Ware, John E; Lieberman, Naomi; Tarlov, Alvin R
OBJECTIVE To examine how Asian-American patients’ ratings of primary care performance differ from those of whites, Latinos, and African-Americans. DESIGN Retrospective analyses of data collected in a cross-sectional study using patient questionnaires. SETTING University hospital primary care group practice. PARTICIPANTS In phase 1, successive patients who visited the study site for appointments were asked to complete the survey. In phase 2, successive patients were selected who had most recently visited each physician, going back as far as necessary to obtain 20 patients for each physician. In total, 502 patients were surveyed, 5% of whom were Asian-American. MAIN RESULTS After adjusting for potential confounders, Asian-Americans rated overall satisfaction and 10 of 11 scales assessing primary care significantly lower than whites did. Dimensions of primary care that were assessed include access, comprehensiveness of care, integration, continuity, clinical quality, interpersonal treatment, and trust. There were no differences for the scale of longitudinal continuity. On average, the rating scale scores of Asian-Americans were 12 points lower than those of whites (on 100-point scales). CONCLUSIONS We conclude that Asian-American patients rate physician primary care performance lower than do whites, African-Americans, and Latinos. Future research needs to focus on Asian-Americans to determine the generalizability of these findings and the extent to which they reflect differences in survey response tendencies or actual quality differences. PMID:9127228
Tanguay, Simon; Awde, Murray; Brock, Gerald; Casey, Richard; Kozak, Joseph; Lee, Jay; Nickel, J. Curtis; Saad, Fred
Benign prostatic hyperplasia (BPH), and its clinical manifestation as lower urinary tract symptoms (LUTS), is a major health concern for aging men. There have been significant advances in the diagnosis and treatment of BPH in recent years. There has been a renewed interest in medical therapies and less invasive surgical techniques. As a consequence, the treatment needs of men with mild to moderate LUTS without evidence of prostate cancer can now be accomplished in a primary care setting. There are differences in the way urologists and primary care physicians approach the evaluation and management of LUTS due to BPH, which is not reflected in Canadian Urological Association (CUA) and American Urological Association (AUA) guidelines. A “shared care” approach involving urologists and primary care physicians represents a reasonable and viable model for the care of men suffering from LUTS. The essence of the model centres around educating and communicating effectively with the patient on BPH. This article provides primary care physicians with an overview of the diagnostic and management strategies outlined in recent CUA and AUA guidelines so that they may be better positioned to effectively deal with this patient population. It is now apparent that we must move away from the urologist as the first-line physician, and allow primary care physicians to accept a new role in the diagnosis and management of BPH. PMID:19543429
Parmar, Jasneet; Dobbs, Bonnie; McKay, Rhianne; Kirwan, Catherine; Cooper, Tim; Marin, Alexandra; Gupta, Nancy
Abstract Objective To assess the current identification and management of patients with dementia in a primary care setting; to determine the accuracy of identification of dementia by primary care physicians; to examine reasons (triggers) for referral of patients with suspected dementia to the geriatric assessment team (GAT) from the primary care setting; and to compare indices of identification and management of dementia between the GAT and primary care network (PCN) physicians and between the GAT and community care (CC). Design Retrospective chart review and comparisons, based on quality indicators of dementia care as specified in the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, were conducted from matching charts obtained from 3 groups of health care providers. Setting Semirural region in the province of Alberta involving a PCN, CC, and a GAT. Participants One hundred patients who had been assessed by the GAT randomly selected from among those diagnosed with dementia or mild cognitive impairment by the GAT. Main outcome measures Diagnosis of dementia and indications of high-quality dementia care listed in PCN, CC, and GAT charts. Results Only 59% of the patients diagnosed with dementia by the GAT had a documented diagnosis of dementia in their PCN charts. None of the 12 patients diagnosed with mild cognitive impairment by the GAT had been diagnosed by the PCN. Memory decline was the most common reason for referral to the GAT. There were statistically significant differences between the PCN and the GAT on all quality indicators of dementia, with underuse of diagnostic and functional assessment tools and lack of attention to wandering, driving, medicolegal, and caregiver issues, and underuse of community supports in the PCN. There was higher congruence between CC and the GAT on assessment and care indices. Conclusion Dementia care remains a challenge in primary care. Within our primary care setting, there are opportunities for
Davis, Tracy; Teaster, Pamela B.; Thornton, Alice; Watkins, John F.; Alexander, Linda; Zanjani, Faika
Purpose To explore primary care providers' HIV prevention practices for older adults. Primary care providers' perceptions and awareness were explored to understand factors that affect their provision of HIV prevention materials and HIV screening for older adults. Design and Method Data were collected through 24 semistructured interviews with primary care providers (i.e., physicians, physician assistants, and nurse practitioners) who see patients older than 50 years. Results Results reveal facilitators and barriers of HIV prevention for older adults among primary care providers and understanding of providers' HIV prevention practices and behaviors. Individual, patient, institutional, and societal factors influenced HIV prevention practices among participants, for example, provider training and work experience, lack of time, discomfort in discussing HIV/AIDS with older adults, stigma, and ageism were contributing factors. Furthermore, factors specific to primary and secondary HIV prevention were identified, for instance, the presence of sexually transmitted infections influenced providers' secondary prevention practices. Implications HIV disease, while preventable, is increasing among older adults. These findings inform future research and interventions aimed at increasing HIV prevention practices in primary care settings for patients older than 50. PMID:25736425
García-Garrido, A B; Caballero, L G; Basiuk, S
Primary care should be the cornerstone of any health system. It is the first contact with the community health system of any country. The Declaration of Alma-Ata, 1978, seeks to provide the basis for the construction of a new health system that will allow the full exercise of the right to health. Carrying out an external rotation in Primary Care in Posadas, Misiones Province, Argentina, during medical training, in family medicine, offers an insight into how other health systems work, provide health care to the community in a Primary Care Center in a country with its similarities and differences like ours, follow the implementation of programs, working with family medicine residents in another country, and living a rewarding personal and professional experience.
Bass del Campo, Germán Camilo
The public health system in Chile does not have a comprehensive development policy for physician resources in primary care, so there is currently a significant deficit of hours for medical care. The article contains a proposal for a "General Program for Primary Care Physicians", which aims to reduce the gap of general practitioners and specialists in primary care. The program proposes to integrate newly graduated physicians to work in the public medical offices with the subsequent possibility of applying for a scholarship specialty, and consecutively a return period as a specialist in the public health network. The immediate implementation of this program is perfectly feasible given the current availability of doctors, over 1400 medical graduates from universities.
Provost, Sylvie; Pineault, Raynald; Tousignant, Pierre; Roberge, Danièle; Tremblay, Dominique; Breton, Mylaine; Benhadj, Lynda; Diop, Mamadou; Fournier, Michel; Brousselle, Astrid
Objective. To analyze the impact of patients' experience of care at their usual source of primary care on their choice of point of entry into cancer investigation process, time to diagnosis, and presence of metastatic cancer at time of diagnosis. Method. A questionnaire was administered to 438 patients with cancer (breast, lung, and colorectal) between 2011 and 2013 in four oncology clinics of Quebec (Canada). Multiple regression analyses (logistic and Cox models) were conducted. Results. Among patients with symptoms leading to investigation of cancer (n = 307), 47% used their usual source of primary care as the point of entry for investigation. Greater comprehensiveness of care was associated with the decision to use this source as point of entry (OR = 1.25; CI 90% = 1.06–1.46), as well as with shorter times between first symptoms and investigation (HR = 1.11; p = 0.05), while greater accessibility was associated with shorter times between investigation and diagnosis (HR = 1.13; p < 0.01). Conclusion. Experience of care at the usual source of primary care has a slight influence on the choice of point of entry for cancer investigation and on time to diagnosis. This influence appears to be more related to patients' perceptions of the accessibility and comprehensiveness of their usual source of primary care. PMID:26504599
Beer, Daniel; Gravier, Bruno
Detention is a severe and psychologically traumatising form of withdrawal from society of people who, often, are already jeopardized or suffering from psychical or somatic diseases. Yet, the individual deprived of freedom has fundamental rights to obtain medical care that should be of equal quality than the general population. One of the numerous missions of the penitentiary practitioner is to fulfil his practice with total independence within a repressive environment, with multiple constraints of order, respecting both security and judiciary requirements and the fundamental ethical principles of penitentiary medicine.
Phillips, Shawn; Seiverling, Elizabeth; Silvis, Matthew
Pressure and friction injuries are common throughout the lifespan. A detailed history of the onset and progression of friction and pressure injuries is key to aiding clinicians in determining the underlying mechanism behind the development of the injury. Modifying or removing the forces that are creating pressure or friction is the key to both prevention and healing of these injuries. Proper care of pressure and friction injuries to the skin is important to prevent the development of infection. Patient education on positioning and ergonomics can help to prevent recurrence of pressure and friction injuries.
Bowen, Sarah; Botting, Ingrid; Huebner, Lori-Anne; Wright, Brock; Beaupre, Beth; Permack, Sheldon; Jones, Ian; Mihlachuk, Ainslie; Edwards, Jeanette; Rhule, Chris
Abstract Objective To determine effective strategies for introducing physician assistants (PAs) in primary care settings and provide guidance to support ongoing provincial planning for PA roles in primary care. Design Time-series research design using multiple qualitative methods. Setting Manitoba. Participants Physician assistants, supervising family physicians, clinic staff, members of the Introducing Physician Assistants into Primary Care Steering Committee, and patients receiving care from PAs. Methods The PA role was evaluated at 6 health care sites between 2012 and 2014; sites varied in size, funding models, geographic locations (urban or rural), specifics of the PA role, and setting type (clinic or hospital). Semistructured interviews and focus groups were conducted; patient feedback on quality improvement was retrieved; observational methods were employed; and documents were reviewed. A baseline assessment was conducted before PA placement. In 2013, there was a series of interviews and focus groups about the introduction of PAs at the 3 initial sites; in 2014 interviews and focus groups included all 6 sites. Main findings The concerns that were expressed during baseline interviews about the introduction of PAs (eg, community and patient acceptance) informed planning. Most concerns that were identified did not materialize. Supervising family physicians, site staff, and patients were enthusiastic about the introduction of PAs. There were a few challenges experienced at the site level (eg, front-desk scheduling), but they were perceived as manageable. Unanticipated challenges at the provincial level were identified (eg, diagnostic test ordering). Increased attachment and improved access—the goals of introducing PAs to primary care—were only some of the positive effects that were reported. Conclusion This first systematic multisite evaluation of PAs in primary care in Canada demonstrated that with appropriate collaborative planning, PAs can effectively
Ozechowski, Timothy J; Becker, Sara J; Hogue, Aaron
The Screening, Brief Intervention and Referral to Treatment (SBIRT) model is widely recommended as part of routine visits in pediatric primary care despite a dearth of evidence on its effectiveness, feasibility, and developmental appropriateness for adolescents in this setting. The purpose of this article is to explicate ways that SBIRT may be tailored to better serve adolescents in primary care under a set of recommended adaptations that we refer to collectively as SBIRT-A or Screening, Brief Intervention, and Referral to Treatment for Adolescents. Each component of the SBIRT-A framework incorporates recommendations to optimize developmental fit with adolescents based on extant empirical research, developmental theory, and well-documented barriers to service delivery in primary care. Commonalities across proposed adaptations include reliance upon proactive methods to identify and engage youth; innovation in service delivery aimed at improving the consistency and reach of interventions; and a family-focused approach to engagement, assessment, and intervention. Specific recommendations include taking advantage of every clinical encounter with the family to screen, involving caregivers in assessments and brief interventions, leveraging technology to administer brief interventions and booster sessions, and patient- and family-centered procedures for treatment referral and engagement. The adaptations proposed in this article have the potential to enhance the detection of adolescents with SU problems in primary care, the consistency of intervention provision, and engagement of this typically recalcitrant population into appropriate treatment.
Fraser, Simon DS; Blakeman, Tom
Chronic kidney disease (CKD) is an important and common noncommunicable condition globally. In national and international guidelines, CKD is defined and staged according to measures of kidney function that allow for a degree of risk stratification using commonly available markers. It is often asymptomatic in its early stages, and early detection is important to reduce future risk. The risk of cardiovascular outcomes is greater than the risk of progression to end-stage kidney disease for most people with CKD. CKD also predisposes to acute kidney injury – a major cause of morbidity and mortality worldwide. Although only a small proportion of people with CKD progress to end-stage kidney disease, renal replacement therapy (dialysis or transplantation) represents major costs for health care systems and burden for patients. Efforts in primary care to reduce the risks of cardiovascular disease, acute kidney injury, and progression are therefore required. Monitoring renal function is an important task, and primary care clinicians are well placed to oversee this aspect of care along with the management of modifiable risk factors, particularly blood pressure and proteinuria. Good primary care judgment is also essential in making decisions about referral for specialist nephrology opinion. As CKD commonly occurs alongside other conditions, consideration of comorbidities and patient wishes is important, and primary care clinicians have a key role in coordinating care while adopting a holistic, patient-centered approach and providing continuity. This review aims to summarize the vital role that primary care plays in predialysis CKD care and to outline the main considerations in its identification, monitoring, and clinical management in this context. PMID:27822135
Draper, Kevin; Gourevitch, Rebecca; Cross, Dori A.; Scholle, Sarah Hudson
Objective Consensus that enhanced teamwork is necessary for efficient and effective primary care delivery is growing. We sought to identify how electronic health records (EHRs) facilitate and pose challenges to primary care teams as well as how practices are overcoming these challenges. Methods Practices in this qualitative study were selected from those recognized as patient-centered medical homes via the National Committee for Quality Assurance 2011 tool, which included a section on practice teamwork. We interviewed 63 respondents, ranging from physicians to front-desk staff, from 27 primary care practices ranging in size, type, geography, and population size. Results EHRs were found to facilitate communication and task delegation in primary care teams through instant messaging, task management software, and the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses (which can offload work from physicians). Areas where respondents felt that electronic medical record EHR functionalities were weakest and posed challenges to teamwork included the lack of integrated care manager software and care plans in EHRs, poor practice registry functionality and interoperability, and inadequate ease of tracking patient data in the EHR over time. Discussion Practices developed solutions for some of the challenges they faced when attempting to use EHRs to support teamwork but wanted more permanent vendor and policy solutions for other challenges. Conclusions EHR vendors in the United States need to work alongside practicing primary care teams to create more clinically useful EHRs that support dynamic care plans, integrated care management software, more functional and interoperable practice registries, and greater ease of data tracking over time. PMID:25627278
Nora, Carlise Rigon Dalla; Junges, José Roque
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
... Administration Advisory Committee on Training in Primary Care Medicine and Dentistry AGENCY: Health Resources and... the cancellation of the Advisory Committee on Training in Primary Care Medicine and...
Turkish primary mathematics curriculum emphasizes the role of problem solving for teaching mathematics and pays particular attention to problem solving strategies. Patterns as a subject and the use of patterns as a non-routine problem solving strategy are also emphasized in the curriculum. The primary purpose of this study was to determine how…
Nitardy, Charlotte M; Duke, Naomi N; Pettingell, Sandra L; Borowsky, Iris W
Routine health care plays a central role in health promotion and disease prevention for children and in reducing health disparities. The purpose of this study is to examine the prevalence of routine physical examination among racially and ethnically diverse adolescents at 5 different time points. The study used data from the Minnesota Student Survey. Measures include frequency of physical examination by race/ethnicity, poverty status, and family structure. The analytic sample included 351 510 adolescents (1998, n = 67 239; 2001, n = 69 177; 2004, n = 71 084; 2007, n = 72 312; and 2010, n = 71 698). There were significant differences by racial/ethnic group at each time point. For example, in 2010, never having a physical examination was reported by 9.2% American Indian, 8.7% Asian American/Pacific Islander, 7.0% Hispanic/Latino, 4.3% Black/African American, 3.7% mixed race, and 2.6% of White respondents (P < .001). Patterns of association emerged when the measure of routine physical examination was stratified by poverty and family structure.
HIV Prevention Counseling Intervention Delivered During Routine Clinical Care Reduces HIV Risk Behavior in HIV-Infected South Africans Receiving Antiretroviral Therapy: The Izindlela Zokuphila/Options for Health Randomized Trial
Fisher, Jeffrey D.; Cornman, Deborah H.; Shuper, Paul A.; Christie, Sarah; Pillay, Sandy; Macdonald, Susan; Ngcobo, Ntombenhle; Amico, K. Rivet; Lalloo, Umesh; Friedland, Gerald; Fisher, William A.
Context Sustainable interventions are needed to minimize HIV risk behavior among people living with HIV (PLWH) in South Africa on antiretroviral therapy (ART), a significant proportion of whom do not achieve viral suppression. Objective To determine whether a brief lay counselor delivered intervention implemented during routine care can reduce risky sex among PLWH on ART. Design Cluster randomized 16 HIV clinical care sites in KwaZulu Natal, South Africa, to intervention or standard-of-care. Setting Publicly funded HIV clinical care sites. Patients 1891 PLWH on ART received the HIV prevention counseling intervention (n = 967) or standard-of-care counseling (n = 924). Intervention Lay counselors delivered a brief intervention using motivational interviewing strategies based on the Information—Motivation—Behavioral Skills (IMB) model during routine clinical care. Main Outcome Measures Number of sexual events without a condom in the past four weeks with partners of any HIV status, and with partners perceived to be HIV-negative or HIV-status unknown, assessed at baseline, 6, 12, and 18 months. Results Intervention participants reported significantly greater reductions in HIV risk behavior on both primary outcomes, compared to standard-of-care participants. Differences in STI incidence between arms were not observed. Conclusion Effective behavioral interventions, delivered by lay counselors within the clinical care setting, are consistent with the strategy of linking HIV care and HIV prevention and integrating biomedical and behavioral approaches to stemming the HIV epidemic. PMID:25230288
Seid, Michael; Stevens, Gregory D
Objective To examine whether and how different kinds of access to care (financial, potential, and realized) predict parent-report child primary care experiences in an urban community sample. Data Sources/Study Setting A prospective cohort study was performed. Baseline survey data were collected (67 percent response rate) from 3,406 parents of kindergarten through sixth grade students in a large urban school district in California during the 1999–2000 school year. A 1-year survey (80.4 percent response rate) resulted in a final sample of 2,738. Study Design Data were analyzed using multiple regression models with robust estimation. The dependent variable was Time 2 parent reports of primary care experiences, assessed via the Parents' Perceptions of Primary Care (P3C) measure. The independent variables were financial access (insurance status), potential access (presence of a regular source of care), and realized access (foregone care), controlling for child and family characteristics (race/ethnicity, parent's language, mother's education level, and child chronic health condition status) and baseline P3C scores. Data Collection Data were collected by mail, telephone, and in person in English, Spanish, Vietnamese, and Tagalog. Principal Findings Controlling for baseline P3C scores and child and family characteristics, having no health insurance at both baseline and Time 2 was associated with a 6.2-point lower Time 2 P3C score, relative to having had health insurance at both time points. Having a regular provider at Time 2 (either always having had one or gaining one during the year) was associated with, on average, a 10-point higher Time 2 P3C score, compared to children without a regular provider (either never having had one or losing one during the year). Episodes of foregone care during the year were associated with 10.7 points lower Time 2 P3C scores, relative to children whose parents did not report foregone care. Similar relationships were found between all
Kennedy, Denise M; Nordrum, Jon T; Edwards, Frederick D; Caselli, Richard J; Berry, Leonard L
A framework for improving health care service quality was implemented at a 12-provider family medicine practice in 2010. A national patient satisfaction research vendor conducted weekly telephone surveys of 840 patients served by that practice: 280 patients served in 2009, and 560 served during 2010 and 2011. After the framework was implemented, the proportion of "excellent" ratings of provider service (the highest rating on a 5-point scale) increased by 5% to 9%, most notably thoroughness (P = .04), listening (P = .04), and explaining (P = .04). Other improvements included prompt test result notification and telephone staff courtesy (each by 10%, P = .02), as well as teamwork (by 8%, P = .04). Overall quality increased by 10% (P = .01), moving the practice from the 68th to the 91st percentile of medical practices in the research vendor's database. Improvements in patient satisfaction suggest that this framework may be useful in value-based payment models.
Ahonen, Lia; Degner, Jurgen
One prerequisite for effective institutional care is that staff agree on how to deliver treatment and have a unified view of how to achieve change--in other words, to have staff group unanimity (SGU). This study used the Correctional Program Assessment Inventory (CPAI) 2000, interviews with key staff, and observations of daily activities to…
Wei, Xiaolin; Yin, Jia; Wong, Samuel Y.S.; Griffiths, Sian M.; Zou, Guanyang; Shi, Leiyu
Abstract Ownership of primary care providers varies in different cities in China. Shanghai represented the full public ownership model of primary providers; Shenzhen had public-owned but private-operated providers; and Hong Kong represented the full private ownership. The study aims to assess the association of primary care ownership and patient perceived quality of care in 3 Chinese megacities. We conducted multistage stratified random surveys in 2013 in the 3 cities. Quality scores of primary care were measured using the validated primary care assessment tools. Multivariate linear regression models were used to compare quality scores after controlling potential confounders of patient demographic, socioeconomic, and healthcare utilization factors. Overall, 797 primary care users in Shanghai, 802 in Shenzhen, and 1325 in Hong Kong participated in the study. The mean total quality scores were reported the highest in Shanghai (28.39), followed by Shenzhen (25.82) and then Hong Kong (25.21) (P < 0.001). Shanghai participants reported the highest scores for 1st contact accessibility, coordination of information, comprehensiveness of service availability, and culture competence, while Hong Kong participants reported the lowest for these domains (P < 0.001). Hong Kong participants from rich households reported higher total scores than those from poor households (P < 0.05); however, this was not found in Shanghai and Shenzhen. The study suggests that private primary care ownership may be associated with lower quality and less equitable care distribution. In China, it suggests that it may be beneficial to promote public-owned and nonprofit providers. Promoting privatization in primary care may be at the cost of quality and equity of primary care. PMID:28072718
Lindley, Lisa C.; Nageswaran, Savithri
Objectives To examine the relationship between pediatric primary care involvement and hospice and home health care use at end of life. Methods California Medicaid data were used to estimate the relationship between pediatric primary care involvement and use of hospice and home health care using generalized estimating equations. Results Of the 2,037 children who died between 2007 and 2010, 11% used hospice and 23% home health. Among all children, primary care was not related to hospice use and was associated with home health use [usual source of care (OR=1.83, p<0.05), comprehensive care (OR=1.60, p<0.05), continuous care (low: OR=1.49, p<0.05; moderate: OR=2.57, p<0.05; high: OR=2.12, p<0.05)]. Primary care for children 15 to 20 years was related to hospice use [usual source of care (OR=4.06, p<0.05), continuous care (low: OR=4.92, p<0.05; moderate OR=4.09, p<0.05; high OR=3.92, p<0.05)]. Primary care for children under 5 years was associated with home health use [usual source of care (OR=2.59, p<0.05), comprehensive care (OR=2.49, p<0.05), continuous care (low: OR=2.22, p<0.05; moderate: OR=3.64, p<0.05; high: OR=3.62, p<0.05)]. For children 6 to 14 years, this association was seen with continuous care [moderate: (OR=2.38, p<0.05); high (OR=2.13, p<0.05)]. Home health for children 15 to 20 years was related to continuous care [moderate: (OR=2.32, p<0.05)]. Conclusions Primary care involvement affected hospice use among older age groups and home health use among younger age groups. These findings underscore the need for clinical knowledge about end-of-life care for children of all ages among primary care providers. PMID:26430133
Ahia, Chad L.; Blais, Christopher M.
Background Primary palliative care consists of the palliative care competencies required of all primary care clinicians. Included in these competencies is the ability to assist patients and their families in establishing appropriate goals of care. Goals of care help patients and their families understand the patient's illness and its trajectory and facilitate medical care decisions consistent with the patient's values and goals. General internists and family medicine physicians in primary care are central to getting patients to articulate their goals of care and to have these documented in the medical record. Case Report Here we present the case of a 71-year-old male patient with chronic obstructive pulmonary disorder, congestive heart failure, and newly diagnosed Alzheimer dementia to model pertinent end-of-life care communication and discuss practical tips on how to incorporate it into practice. Conclusion General internists and family medicine practitioners in primary care are central to eliciting patients' goals of care and achieving optimal end-of-life outcomes for their patients. PMID:25598737
Hollander, Marcus J; Kadlec, Helena
Context: In its fee-for-service funding model for primary care, British Columbia, Canada, introduced incentive payments to general practitioners as pay for performance for providing enhanced, guidelines-based care to patients with chronic conditions. Evaluation of the program was conducted at the health care system level. Objective: To examine the impact of the incentive payments on annual health care costs and hospital utilization patterns in British Columbia. Design: The study used Ministry of Health administrative data for Fiscal Year 2010–2011 for patients with diabetes, congestive heart failure, chronic obstructive pulmonary disease, and/or hypertension. In each disease group, cost and utilization were compared across patients who did, and did not, receive incentive-based care. Main Outcome Measures: Health care costs (eg, primary care, hospital) and utilization measures (eg, hospital days, readmissions). Results: After controlling for patients’ age, sex, service needs level, and continuity of care (defined as attachment to a general practice), the incentives reduced the net annual health care costs, in Canadian dollars, for patients with hypertension (by approximately Can$308 per patient), chronic obstructive pulmonary disease (by Can$496), and congestive heart failure (by Can$96), but not diabetes (incentives cost about Can$148 more per patient). The incentives were also associated with fewer hospital days, fewer admissions and readmissions, and shorter lengths of hospital stays for all 4 groups. Conclusion: Although the available literature on pay for performance shows mixed results, we showed that the funding model used in British Columbia using incentive payments for primary care might reduce health care costs and hospital utilization. PMID:26263389
Taira, D A; Safran, D G; Seto, T B; Rogers, W H; Inui, T S; Montgomery, J; Tarlov, A R
OBJECTIVE: To determine if patient assessments (reports and ratings) of primary care differ by patient ethnicity. DATA SOURCES/STUDY DESIGN: A self-administered patient survey of 6,092 Massachusetts employees measured seven defining characteristics of primary care: (1) access (financial, organizational); (2) continuity (longitudinal, visit based); (3) comprehensiveness (knowledge of patient, preventive counseling); (4) integration; (5) clinical interaction (communication, thoroughness of physical examinations); (6) interpersonal treatment; and (7) trust. The study employed a cross-sectional observational design. PRINCIPAL FINDINGS: Asians had the lowest primary care performance assessments of any ethnic group after adjustment for socioeconomic and other factors. For example, compared to whites, Asians had lower scores for communication (69 vs. 79, p = .001) and comprehensive knowledge of patient (56 vs. 48, p = .002), African Americans and Latinos had less access to care, and African Americans had less longitudinal continuity than whites. CONCLUSIONS: We do not know what accounts for the observed differences in patient assessments of primary care. The fact that patient reports as well as the more subjective ratings of care differed by ethnicity suggests that quality differences might exist that need to be addressed. PMID:11775667
Wasco, Sharon M; Campbell, Rebecca
This study assumes that rape victim advocates who provide community outreach services to victimized women must adjust to a heightened awareness of sexual violence to do their jobs. Using qualitative methodology, this multiple case study explored rape victim advocates' strategies for incorporating repeated exposure to sexual assault into their daily lives as well as ways that organizations can support such endeavors. Findings suggest that advocates' self-care routines draw upon various personal resources (i.e., cognitive, physical, social, spiritual, verbal), and serve 2 roles for coping with rape-related pain: (a) cathartic releasing of traumatic material, and (b) improving capacity to integrate the traumatic material into one's life. Additionally, over 20 organizational characteristics that workers perceive to be supportive (e.g., weekly meetings, flexible hours) were identified. Nonparametric and categorical statistical analyses were used to analyze the relationship between organizational support and self-care routines, finding that advocates working in organizations with higher levels of support utilize more strategies that are integrative in nature. Implications of these findings are discussed.
Green, Lawrence W.; Glanz, Karen; Ayanian, John Z.; Mittman, Brian S.; Chollette, Veronica; Rubenstein, Lisa V.
The promise of widespread implementation of efficacious interventions across the cancer continuum into routine practice and policy has yet to be realized. Multilevel influences, such as communities and families surrounding patients or health-care policies and organizations surrounding provider teams, may determine whether effective interventions are successfully implemented. Greater recognition of the importance of these influences in advancing (or hindering) the impact of single-level interventions has motivated the design and testing of multilevel interventions designed to address them. However, implementing research evidence from single- or multilevel interventions into sustainable routine practice and policy presents substantive challenges. Furthermore, relatively few multilevel interventions have been conducted along the cancer care continuum, and fewer still have been implemented, disseminated, or sustained in practice. The purpose of this chapter is, therefore, to illustrate and examine the concepts underlying the implementation and spread of multilevel interventions into routine practice and policy. We accomplish this goal by using a series of cancer and noncancer examples that have been successfully implemented and, in some cases, spread widely. Key concepts across these examples include the importance of phased implementation, recognizing the need for pilot testing, explicit engagement of key stakeholders within and between each intervention level; visible and consistent leadership and organizational support, including financial and human resources; better understanding of the policy context, fiscal climate, and incentives underlying implementation; explication of handoffs from researchers to accountable individuals within and across levels; ample integration of multilevel theories guiding implementation and evaluation; and strategies for long-term monitoring and sustainability. PMID:22623601
Northridge, Mary E.; Birenz, Shirley; Gomes, Danni; Golembeski, Cynthia A.; Greenblatt, Ariel Port; Shelley, Donna; Russell, Stefanie L.
Purpose There is a need for research to facilitate the widespread implementation, dissemination, and sustained utilization of evidence-based primary care screening, monitoring, and care coordination guidelines, thereby increasing the impact of dental hygienists’ actions on patients’ oral and general health. The aims of this formative study are to: (1) explore dental hygienists’ and dentists’ perspectives regarding the integration of primary care activities into routine dental care; and (2) assess the needs of dental hygienists and dentists regarding primary care coordination activities and use of information technology to obtain clinical information at chairside. Methods This qualitative study recruited ten hygienists and six dentists from ten New York City area dental offices with diverse patient mixes and volumes. A New York University faculty hygienist conducted semi-structured, in-depth interviews, which were digitally recorded and transcribed verbatim. Data analysis consisted of multilevel coding based on the Consolidated Framework for Implementation Research, resulting in emergent themes with accompanying categories. Results The dental hygienists and dentists interviewed as part of this study fail to use evidence-based guidelines to screen their patients for primary care sensitive conditions. Overwhelmingly, dental providers believe that tobacco use and poor diet contribute to oral disease, and report using electronic devices at chairside to obtain web-based health information. Conclusion Dental hygienists are well positioned to help facilitate greater integration of oral and general health care. Challenges include lack of evidence-based knowledge, coordination between dental hygienists and dentists, and systems-level support, with opportunities for improvement based upon a theory-driven framework. PMID:27340183
Song, Hummy; Chien, Alyna T; Fisher, Josephine; Martin, Julia; Peters, Antoinette S; Hacker, Karen; Rosenthal, Meredith B; Singer, Sara J
Objective To develop and validate a survey instrument designed to measure team dynamics in primary care. Data Sources/Study Setting We studied 1,080 physician and nonphysician health care professionals working at 18 primary care practices participating in a learning collaborative aimed at improving team-based care. Study Design We developed a conceptual model and administered a cross-sectional survey addressing team dynamics, and we assessed reliability and discriminant validity of survey factors and the overall survey's goodness-of-fit using structural equation modeling. Data Collection We administered the survey between September 2012 and March 2013. Principal Findings Overall response rate was 68 percent (732 respondents). Results support a seven-factor model of team dynamics, suggesting that conditions for team effectiveness, shared understanding, and three supportive processes are associated with acting and feeling like a team and, in turn, perceived team effectiveness. This model demonstrated adequate fit (goodness-of-fit index: 0.91), scale reliability (Cronbach's alphas: 0.71–0.91), and discriminant validity (average factor correlations: 0.49). Conclusions It is possible to measure primary care team dynamics reliably using a 29-item survey. This survey may be used in ambulatory settings to study teamwork and explore the effect of efforts to improve team-based care. Future studies should demonstrate the importance of team dynamics for markers of team effectiveness (e.g., work satisfaction, care quality, clinical outcomes). PMID:25423886
Patel, Sapana R.; Gorritz, Magdaliz; Olfson, Mark; Bell, Michelle A.; Jackson, Elizabeth; Sánchez-Lacay, J. Arturo; Alfonso, César; Leeman, Eve; Lewis-Fernández, Roberto
Objective Toevaluate a quality improvementintervention to improve thescreening and management (e.g., referral to psychiatric care) of common mental disorders in small independent Latino primary care practices serving patient populations of predominantly low-income Latino immigrants. Methods In 7 practices, academic detailing and consultation/liaison psychiatry were first implemented (Stage 1) and then supplemented withappointment scheduling and reminders to primary care physicians (PCP’s) by clinic staff (Stage 2).Acceptability and feasibility were assessed with independent patient samples during each stage. Results Participating PCP found the interventions acceptable and noted that referrals to language-matched specialty care and case-by-case consultation on medication management were particularly beneficial. The academic detailing and consultation/liaison intervention (Stage 1) did not significantly affect PCP screening, management or patient satisfaction with care. When support for appointment scheduling and reminders (Stage 2) was added, however, PCP referral to psychiatric services increased (p=.04) and referred patients were significantly more likely to follow through and have more visits to mental health professionals (p=.04). Conclusion Improving the quality of mental health care in low-resourced primary care settings may require academic detailing and consultation/liaison psychiatric intervention supplemented with staff outreach to achieve meaningful improvement in the processes of care. PMID:26598287
Reamy, Brian V; Derby, Richard; Bunt, Christopher W
Although easily examined, abnormalities of the tongue can present a diagnostic and therapeutic dilemma for physicians. Recognition and diagnosis require a thorough history, including onset and duration, antecedent symptoms, and tobacco and alcohol use. Examination of tongue morphology and a careful assessment for lymphadenopathy are also important. Geographic tongue, fissured tongue, and hairy tongue are the most common tongue problems and do not require treatment. Median rhomboid glossitis is usually associated with a candidal infection and responds to topical antifungals. Atrophic glossitis is often linked to an underlying nutritional deficiency of iron, folic acid, vitamin B12, riboflavin, or niacin and resolves with correction of the underlying condition. Oral hairy leukoplakia, which can be a marker for underlying immunodeficiency, is caused by the Epstein-Barr virus and is treated with oral antivirals. Tongue growths usually require biopsy to differentiate benign lesions (e.g., granular cell tumors, fibromas, lymphoepithelial cysts) from premalignant leukoplakia or squamous cell carcinoma. Burning mouth syndrome often involves the tongue and has responded to treatment with alpha-lipoic acid, clonazepam, and cognitive behavior therapy in controlled trials. Several trials have also confirmed the effectiveness of surgical division of tongue-tie (ankyloglossia), in the context of optimizing the success of breastfeeding compared with education alone. Tongue lesions of unclear etiology may require biopsy or referral to an oral and maxillofacial surgeon, head and neck surgeon, or a dentist experienced in oral pathology.
Lee, Linda; Hillier, Loretta M; Heckman, George; Gagnon, Micheline; Borrie, Michael J; Stolee, Paul; Harvey, David
The implementation in Ontario of 15 primary-care-based interprofessional memory clinics represented a unique model of team-based case management aimed at increasing capacity for dementia care at the primary-care level. Each clinic tracked referrals; in a subset of clinics, charts were audited by geriatricians, clinic members were interviewed, and patients, caregivers, and referring physicians completed satisfaction surveys. Across all clinics, 582 patients were assessed, and 8.9 per cent were referred to a specialist. Patients and caregivers were very satisfied with the care received, as were referring family physicians, who reported increased capacity to manage dementia. Geriatricians' chart audits revealed a high level of agreement with diagnosis and management. This study demonstrated acceptability, feasibility, and preliminary effectiveness of the primary-care memory clinic model. Led by specially trained family physicians, it provided timely access to high-quality collaborative dementia care, impacting health service utilization by more-efficient use of scarce geriatric specialist resources.
Ratzliff, Anna; Phillips, Kathryn E.; Sugarman, Jonathan R.; Unützer, Jürgen; Wagner, Edward H.
Behavioral health problems are common, yet most patients do not receive effective treatment in primary care settings. Despite availability of effective models for integrating behavioral health care in primary care settings, uptake has been slow. The Behavioral Health Integration Implementation Guide provides practical guidance for adapting and implementing effective integrated behavioral health care into patient-centered medical homes. The authors gathered input from stakeholders involved in behavioral health integration efforts: safety net providers, subject matter experts in primary care and behavioral health, a behavioral health patient and peer specialist, and state and national policy makers. Stakeholder input informed development of the Behavioral Health Integration Implementation Guide and the GROW Pathway Planning Worksheet. The Behavioral Health Integration Implementation Guide is model neutral and allows organizations to take meaningful steps toward providing integrated care that achieves access and accountability. PMID:26698163
Gordon, C; Jackson-Smale, A; Thomson, R
The aim of DILEMMA is to provide tools for the development of decision support systems for use in general medical practice, hospital-based cancer care, and shared care of cancer and cardiology patients. In primary care, the project intends to provide aids to clinical performance in prescribing, referral and the use of clinical guidelines. The demonstrator applications involve telematics and knowledge-based methodology, using an approach termed logic engineering which combines logic programming and software lifecycle methods. DILEMMA will demonstrate systems to assist shared care and home care which should help reduce pressure on secondary health resources and, by disseminating best practice knowledge, improve patient care and patient quality of life.
Boland, R G; Young, M E
Since the 1978 Alma-Alta International Conference on Primary Health Care, investments in primary health care projects throughout the world have been increasing. However, with the exception of China, no national projects have demonstrated the ability to provide longterm comprehensive primary health care in conditions of chronic proverty with local resources. Programs in China, Cuba, and Tanzania have achieved primary health care coverage for 100% of their populations. These countries have in common strong governments that have been able to implement radical changes in the health system. Individual freedoms in these societies have been restricted in favor of improved health. Programs in Nigeria, India, and Afghanistan have been less successful, although some progress has been made in projects using external funds, inspite of a strong committment by the governments. Efforts to reorganize the health care system have lacked needed political strength. Currently, these systems have resulted in less than complete coverage, without the prospect of attaining acceptable levels of infant mortality, life expectancy and net population growth. Economic, political, and cultural costs may be high as for example, national security or traditional practices are traded to achieve primary health care with 100% coverage. WHO has devised a global strategy which, when translated into operational policies will need to address several unresolved issues. These include recognizing that the goal of comprehensive primary health care may not be justified given the lack of progress to date and that effective, selective primary health care focused on nutrition, immunization, control of endemic diseases, and health education may be a more realistic goal; and that a system of international social security may be an effective means of assuring that the poorest countries are able to provide care. In addition, questions concerning continued funding of programs that can never be locally funded, the role
Hope, R; Carter, C A; Rai, I M
Sahar Matha Secondary School and Ghoretar Health Post serve approximately 30,000 people living in scattered communities over the steep foothills of the Himalaya in East Nepal. A pilot health education and sanitation project was implemented with the objectives of giving the secondary school students the knowledge and skills necessary for building domestic pit latrines in their villages. It was hoped that the students could be motivated to create enough awareness of the need for domestic pit latrines so that latrines would continue to be built after the pilot phase of the project. At the end of the 4 week building period there were 150 completed domestic pit latrines and 45 pits or partially complete latrines. Seeing pit latrine in Ghoretar at the school and health post had not been enough to motivate people to build their own domestic pit latrine. It seemed that people could understand the convenience of privacy in an area where there was no jungle cover, but did not appreciate the hygiene reasons for using pit latrines. It is now planned to extend the project into the 19 schools which feed the 2ndarty school, with the 2ndary school boy and girl scouts taking the health messages to the primary schools. Particular attention will be given to the teaching of modes disease transmission. So that the villagers can use their latrines hygienically.
Background Care pathways are widely used in hospitals for a structured and detailed planning of the care process. There is a growing interest in extending care pathways into primary care to improve quality of care by increasing care coordination. Evidence is sparse about the relationship between care pathways and care coordination. The multi-level framework explores care coordination across organizations and states that (inter)organizational mechanisms have an effect on the relationships between healthcare professionals, resulting in quality and efficiency of care. The aim of this study was to assess the extent to which care pathways support or create elements of the multi-level framework necessary to improve care coordination across the primary - hospital care continuum. Methods This study is an in-depth analysis of five existing local community projects located in four different regions in Flanders (Belgium) to determine whether the available empirical evidence supported or refuted the theoretical expectations from the multi-level framework. Data were gathered using mixed methods, including structured face-to-face interviews, participant observations, documentation and a focus group. Multiple cases were analyzed performing a cross case synthesis to strengthen the results. Results The development of a care pathway across the primary-hospital care continuum, supported by a step-by-step scenario, led to the use of existing and newly constructed structures, data monitoring and the development of information tools. The construction and use of these inter-organizational mechanisms had a positive effect on exchanging information, formulating and sharing goals, defining and knowing each other’s roles, expectations and competences and building qualitative relationships. Conclusion Care pathways across the primary-hospital care continuum enhance the components of care coordination. PMID:23919518
Ladden, Maryjoan D; Bodenheimer, Thomas; Fishman, Nancy W; Flinter, Margaret; Hsu, Clarissa; Parchman, Michael; Wagner, Edward H
Many primary care practices are changing the roles played by the members of their health care teams. The purpose of this article is to describe some of these new roles, using the authors' preliminary observations from 25 site visits to high-performing primary care practices across the United States in 2012-2013. These sites visits, to practices using their workforce creatively, were part of the Robert Wood Johnson Foundation-funded initiative, The Primary Care Team: Learning From Effective Ambulatory Practices.Examples of these new roles that the authors observed on their site visits include medical assistants reviewing patient records before visits to identify care gaps, ordering and administering immunizations using protocols, making outreach calls to patients, leading team huddles, and coaching patients to set self-management goals. The registered nurse role has evolved from an emphasis on triage to a focus on uncomplicated acute care, chronic care management, and hospital-to-home transitions. Behavioral health providers (licensed clinical social workers, psychologists, or licensed counselors) were colocated and integrated within practices and were readily available for immediate consults and brief interventions. Physicians have shifted from lone to shared responsibility for patient panels, with other team members empowered to provide significant portions of chronic and preventive care.An innovative team-based primary care workforce is emerging. Spreading and sustaining these changes will require training both health professionals and nonprofessionals in new ways. Without clinical experiences that model this new team-based care and role models who practice it, trainees will not be prepared to practice as a team.
Sheaff, R; Rogers, A; Pickard, S; Marshall, M; Campbell, S; Sibbald, B; Halliwell, S; Roland, M
In many countries governments are recruiting the medical profession into a more active, transparent regulation of clinical practice. Consequently the medical profession adapts the ways it regulates itself and its relationship to health system managers changes. This paper uses empirical research in English Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) to assess the value of Courpasson's concept of soft bureaucracy as a conceptualisation of these changes. Clinical governance in PCGs and PCTs displays important parallels with governance in soft bureaucracies, but the concept of soft bureaucracy requires modification to make it more applicable to general practice. In English primary care, governance over rank-and-file doctors is exercised by local professional leaders rather than general managers, harnessing their colleagues' perception of threats to professional autonomy and self-regulation rather than fears of competition as the means of 'soft coercion'.
Mills, Rachel; Voora, Deepak; Peyser, Bruce; Haga, Susanne B
Pharmacogenetic testing refers to a type of genetic test to predict a patient’s likelihood to experience an adverse event or not respond to a given drug. Despite revision to several labels of commonly prescribed drugs regarding the impact of genetic variation, the use of this testing has been limited in many settings due to a number of factors. In the primary care setting, the limited office time as well as the limited knowledge and experience of primary care practitioners have likely attributed to the slow uptake of pharmacogenetic testing. This paper provides talking points for primary care physicians to discuss with patients when pharmacogenetic testing is warranted. As patients and physicians become more familiar and accepting of pharmacogenetic testing, it is anticipated that discussion time will be comparable to that of other clinical tests. PMID:24101877
Dawson-Rose, Carol; Draughon, Jessica E; Zepf, Roland; Cuca, Yvette P; Huang, Emily; Freeborn, Kellie; Lum, Paula J
Substance use complicates HIV care and prevention. Primary care clinics are an ideal setting to screen for and offer interventions for unhealthy alcohol and drug use; however, few HIV clinics routinely screen for substance use. We enrolled 208 clinic patients at an urban underserved HIV primary care clinic. We screened the patients for substance use with the Alcohol, Smoking, and Substance Involvement Score Test and measured urine toxicology. Of the 168 participants who completed screening, the majority reported tobacco or nonprescribed substance use in the previous 3 months. More African American participants reported low or no risk amphetamine use compared to Hispanic, White, or Other race participants (p < .001). Implementing standard clinic practice for screening and assessing substance use in HIV primary care clinics is needed.
Tannebaum, Michael; Wilkin, Holley A.; Keys, Jobia
Background: The Affordable Care Act (ACA) was introduced, in part, to increase access to primary care, which has been shown to provide patients with myriad health benefits. Objective: To increase primary care usage by understanding the beliefs about primary and emergency care most salient to those whose healthcare-seeking practices may be impacted…
Barton, Christopher; Reeve, Joanne; Adams, Ann; McIntyre, Ellen
This study was undertaken to provide a snapshot of the academic primary health-care workforce in Australia and to provide some insight into research capacity in academic primary health care following changes to funding for this sector. A convenience sample of individuals self-identifying as working within academic primary health care (n=405) completed an anonymous online survey. Respondents were identified from several academic primary health-care mailing lists. The survey explored workforce demographics, clarity of career pathways, career trajectories and enablers/barriers to 'getting in' and 'getting on'. A mix of early career (41%), mid-career (25%) and senior academics (35%) responded. Early career academics tended to be female and younger than mid-career and senior academics, who tended to be male and working in 'balanced' (teaching and research) roles and listing medicine as their disciplinary background. Almost three-quarters (74%) indicated career pathways were either 'completely' or 'somewhat unclear', irrespective of gender and disciplinary backgrounds. Just over half (51%) had a permanent position. Males were more likely to have permanent positions, as were those with a medical background. Less than half (43%) reported having a mentor, and of the 57% without a mentor, more than two-thirds (69%) would like one. These results suggest a lack of clarity in career paths, uncertainty in employment and a large number of temporary (contract) or casual positions represent barriers to sustainable careers in academic primary health care, especially for women who are from non-medicine backgrounds. Professional development or a mentoring program for primary health-care academics was desired and may address some of the issues identified by survey respondents.
Lee, Jin Yong; Eun, Sang Jun; Kim, Hyun Joo; Jo, Min-Woo
Objective This study aimed to identify private clinics that have a potential to perform the role of primary care providers (PCPs) in a primary care setting in Korea where private specialists are dominant. Methods The 2013 National Patient Sample claim data of Health Insurance Review and Assessment Service in Korea was used. Two-step cluster analysis was performed using characteristics of private clinics, and patient and utilization characteristics of 27,797 private clinics. External validation of clusters was performed by assessing the association among clusters and outcomes of care provided by private clinics. Stability of clusters was cross-validated using discriminant analysis. Results The result classified more than a half of private clinics into a potential PCP cluster. These were private clinics with specialties considered to be those of primary care physicians and were more likely to be located in non-metropolitan areas than specialized PCPs were. Compared to specialized PCPs, they had a higher percentage of pediatric and geriatric patients, patients with greater disease severity, a higher percentage of patients with complex comorbidities or with simple or minor disease groups, a higher number of patients and visits, and the same or higher quality of primary care. The most important factor in explaining variations between PCP clusters was the number of simple or minor disease groups per patient. Conclusion This study identified potential PCPs and suggested the identifying criteria for PCPs. It will provide useful information for formulation of a primary care strengthening policy to policy makers in Korea as well as other countries with similar specialist-dominant primary care settings. PMID:27560181
Objectives To evaluate the evidence relating to the effectiveness of breast self-examination (BSE) to screen for breast cancer and to provide recommendations for routine teaching of BSE to women in various age groups as part of a periodic health examination. Options Routine teaching of BSE to women. Evidence The electronic databases MEDLINE, PreMEDLINE, CINAHL, HealthSTAR, Current Contents and the Cochrane Library were searched for abstracts and full reports of studies published from 1966 to October 2000 that evaluated the effectiveness of BSE in reducing breast cancer mortality. In addition, references of key papers were searched and experts consulted to ensure that all relevant articles had been identified. Outcomes Prevention of death from breast cancer was viewed as the most important outcome; other outcomes examined included the stage of cancer detected, the rate of benign biopsy results, the number of patient visits for breast complaints, and psychological benefits and harms. Values The recommendations of this report reflect the commitment of the Canadian Task Force on Preventive Health Care to provide a structured, evidence-based appraisal of whether a manoeuvre should be included in the periodic health examination. Benefits, harms and costs Breast cancer is the most frequently diagnosed cancer among Canadian women, accounting for 30% of all new cancer cases each year. In 2000 an estimated 19 200 Canadian women would have been diagnosed with breast cancer, and 5500 would have died from the disease. To date, 2 large randomized controlled trials, a quasi-randomized trial, a large cohort study and several case–control studies have failed to show a benefit for regular performance of BSE or BSE education, compared with no BSE. In contrast, there is good evidence of harm from BSE instruction, including significant increases in the number of physician visits for the evaluation of benign breast lesions and significantly higher rates of benign biopsy results
Laughlin, Candia Baker; Beisel, Marie
High-quality, accessible, and efficient primary care is needed as the U.S. health care system undergoes significant change. Advancing the role of registered nurses in the primary care setting is important to the solution. A large academic health center implemented five initiatives to improve the care of chronically ill patients through the expanded role of RNs in the context of the health care team. Role evolution of nurses in the pilots required some continuing education and some additional nursing support to release the pilot nurses from their usual duties. These strategies allowed the nurses to apply interventions that enhanced the coordination of care and promoted patient self-management skills. Some short-term improvements in health status were realized and barriers to self-care were identified and resolved.
Matthews, P; Fletcher, J
General practitioners and practice nurses require the clinical skills that will enable them to detect sexually transmitted infections in the context of a shift to having no, or insidious symptoms. They need to be able to confirm the diagnosis and have clear models for management and referral. Primary care and genitourinary medicine need to work more closely together to increase mutual understanding and clarify the issues which surround referral and attendance. Sexual health risk assessment through the investigation of sexual history is a helpful way forward in both differential diagnosis and in targeting sexual health promotion and care. Many aspects of these clinical skills are specific to the primary care context. There is a need for improved undergraduate, postgraduate, and in-service training. Multidisciplinary educational approaches are ideal for the subject of sexual health. Primary care groups offer a potential way forward to help develop quality in primary care and some are developing health improvement programmes that aim to address sexual health issues. PMID:11271875
Andrade, Rubia Laine de Paula; Scatolin, Beatriz Estuque; Wysocki, Anneliese Domingues; Beraldo, Aline Ale; Monroe, Aline Aparecida; Scatena, Lúcia Marina; Villa, Tereza Cristina Scatena
OBJECTIVE To assess primary health care and emergency medical services performance for tuberculosis diagnosis. METHODS Cross-sectional study were conducted with 90 health professionals from primary health care and 68 from emergency medical services, in Ribeirao Preto, SP, Southeastern Brazil, in 2009. A structured questionnaire based on an instrument of tuberculosis care assessment was used. The association between health service and the variables of structure and process for tuberculosis diagnosis was assessed by Chi-square test, Fisher's exact test (both with 5% of statistical significance) and multiple correspondence analysis. RESULTS Primary health care was associated with the adequate provision of inputs and human resources, as well as with the sputum test request. Emergencial medical services were associated with the availability of X-ray equipment, work overload, human resources turnover, insufficient availability of health professionals, unavailability of sputum collection pots and do not request sputum test. In both services, tuberculosis diagnosis remained as a physician's responsibility. CONCLUSIONS Emergencial medical services presented weaknesses in its structure to identify tuberculosis suspects. Gaps on the process were identified in both primary health care and emergencial medical services. This situation highlights the need for qualification of health services that are the main gateway to health system to meet sector reforms that prioritize the timely diagnosis of tuberculosis and its control. PMID:24626553
A fundamental change occurring for physicians is that there are increasingly organized efforts to comprehensively assess physician performance. Managed care is the factor most instrumental in leading to an enhanced focus on physician measurements. Another major factor that has prompted increased attention to the measurement of physicians' performance is that patients are beginning to act more as consumers of health care. Efforts to measure physician performance in geographically dispersed primary care practices is inherently more difficult than measuring hospital care. However, according to some studies that have attempted to do this, the delivery in primary care offices of basic preventive services and the care given to patients with chronic illnesses is surprisingly poor. If primary care physicians don't address these issues, managed care companies will make it policy to refer some patients with chronic disease to specialists, who are comprehensively achieving higher measurement scores. What is being measured is at present quite variable in different primary care offices. Most of the initial measurements have been from claims data or from other data that might be obtained and aggregated outside of the primary care physician's office. As this data is not very rich in clinical information, significant misinterpretation is possible. In order to augment these shortcomings, office records are increasingly being reviewed. A standardization of primary care physicians' office medical records is rapidly occurring and is being driven by the measurable items reviewed by managed care organizations. Measurement of patient complaints and patient surveys is another means that managed care organizations presently use to assess primary care physicians' performance. Extreme caution should be used when interpreting this data, as often the small numbers of patients, multifactorial issues, and ambiguity about responsible parties may skew the results. Measurement processes are
Bremander, Ann; Bergman, Stefan
Musculoskeletal diseases as a group are one of the most common causes of contact in primary care and the most common causes of disability and long-term sick leave in several Western countries. Pain and dysfunction are often present without any specific findings in the musculoskeletal system, and a strictly biomedical approach is often inadequate. Body structure and function interact with personal and environmental factors, affecting the ability to perform activities and participate in society. It is important to meet these needs in primary care, and non-pharmacological principles such as physical activity and patient education with a cognitive approach are cornerstones in a multimodal management model.
Background Insight into the frequency and seriousness of potentially unsafe situations may be the first step towards improving patient safety. Most patient safety attention has been paid to patient safety in hospitals. However, in many countries, patients receive most of their healthcare in primary care settings. There is little concrete information about patient safety in primary care in the Netherlands. The overall aim of this study was to provide insight into the current patient safety issues in Dutch general practices, out-of-hours primary care centres, general dental practices, midwifery practices, and allied healthcare practices. The objectives of this study are: to determine the frequency, type, impact, and causes of incidents found in the records of primary care patients; to determine the type, impact, and causes of incidents reported by Dutch healthcare professionals; and to provide insight into patient safety management in primary care practices. Design and methods The study consists of three parts: a retrospective patient record study of 1,000 records per practice type was conducted to determine the frequency, type, impact, and causes of incidents found in the records of primary care patients (objective one); a prospective component concerns an incident-reporting study in each of the participating practices, during two successive weeks, to determine the type, impact, and causes of incidents reported by Dutch healthcare professionals (objective two); to provide insight into patient safety management in Dutch primary care practices (objective three), we surveyed organizational and cultural items relating to patient safety. We analysed the incidents found in the retrospective patient record study and the prospective incident-reporting study by type of incident, causes (Eindhoven Classification Model), actual harm (severity-of-outcome domain of the International Taxonomy of Medical Errors in Primary Care), and probability of severe harm or death. Discussion
Govender, Indiran; Mabuza, Langalibalele H; Ogunbanjo, Gboyega A; Mash, Bob
The aim of this article is to provide practical guidance on conducting surveys and the use of questionnaires for postgraduate students at a Masters level who are undertaking primary care research. The article is intended to assist with writing the methods section of the research proposal and thinking through the relevant issues that apply to sample size calculation, sampling strategy, design of a questionnaire and administration of a questionnaire. The articleis part of a larger series on primary care research, with other articles in the series focusing on the structure of the research proposal and the literature review, as well as quantitative data analysis.
Lester, Helen; Matharu, Tatum; Mohammed, Mohammed A; Lester, David; Foskett-Tharby, Rachel
Background Pay for performance is now a widely adopted quality improvement initiative in health care. One of the largest schemes in primary care internationally is the English Quality and Outcomes Framework (QOF). Aim To obtain a longer term perspective on the implementation of the QOF. Design and setting Qualitative study with 47 health professionals in 23 practices across England. Method Semi-structured interviews. Results Pay for performance is accepted as a routine part of primary care in England, with previous more individualistic and less structured ways of working seen as poor practice. The size of the QOF and the evidence-based nature of the indicators are regarded as key to its success. However, pay for performance may have had a negative impact on some aspects of medical professionalism, such as clinical autonomy, and led a significant minority of GPs to prioritise their own pay rather than patients’ best interests. A small minority of GPs tried to increase their clinical autonomy with further unintended consequences. Conclusion Pay for performance indicators are now welcomed by primary healthcare teams and GPs across generations. Almost all interviewees wanted to see a greater emphasis on involving front line practice teams in developing indicators. However, almost all GPs and practice managers described a sense of decreased clinical autonomy and loss of professionalism. Calibrating the appropriate level of clinical autonomy is critical if pay for performance schemes are to have maximal impact on patient care. PMID:23735412
Background Finland has since 1972 had a primary health care system based on health centres run and funded by the local public authorities called ‘municipalities’. On the world map of primary health care systems, the Finnish solution claims to be the most health centre oriented and also the widest, both in terms of the numbers of staff and also of different professions employed. Offering integrated care through multi-professional health centres has been overshadowed by exceptional difficulties in guaranteeing a reasonable access to the population at times when they need primary medical or dental services. Solutions to the problems of access have been found, but they do not seem durable. Description of policy practice During the past 10 years, the health centres have become a ground of active development structural change, for which no end is in sight. Broader issues of municipal and public administration structures are being solved through rearranging primary health services. In these rearrangements, integration with specialist services and with social services together with mergers of health centres and municipalities are occurring at an accelerated pace. This leads into fundamental questions of the benefits of integration, especially if extensive integration leads into the threat of the loss of identity for primary health care. Discussion This article ends with some lessons to be learned from the situation in Finland for other countries. PMID:19590612
Weissman, Myrna M; Hankerson, Sidney H; Scorza, Pamela; Olfson, Mark; Verdeli, Helena; Shea, Steven; Lantigua, Rafael; Wainberg, Milton
Interpersonal Counseling (IPC) comes directly from interpersonal psychotherapy (IPT), an evidenced-based psychotherapy developed by Klerman and Weissman. It [IPC?] is a briefer, more structured version for use primarily in non-mental health settings, such as primary care clinics when treating patients with symptoms of depression. National health-care reform, which will bring previously uninsured persons into care and provide mechanisms to support mental health training of primary care providers, will increase interest in briefer psychotherapy. This paper describes the rationale, development, evidence for efficacy, and basic structure of IPC and also presents an illustrated clinical vignette. The evidence suggests that IPC is efficacious in reducing symptoms of depression; that it can be used by mental health personnel of different levels of training, and that the number of sessions is flexible depending on the context and resources. More clinical trials are needed, especially ones comparing IPC to other types of care used in the delivery of mental health services in primary care.
Stensland, Jeffrey; Brasure, Michelle; Moscovice, Ira
This study evaluates why rural primary care physicians sell their practices. A random sample of rural primary care practices in California, Utah, Ohio, Texas, and Virginia were surveyed to investigate changes in ownership of the practices during the period 1995-1998. These five states were selected because they represent areas with different experiences with physician-hospital integration and varied rates of managed care penetration. A series of logistic regressions were conducted to examine the factors that led independent physicians to sell their practices to either nonlocal buyers, local hospitals, or local physicians. Findings suggest that sales to nonlocal buyers represent the majority of practice ownership changes. The motivations for ceding control to nonlocal buyers center on managed care concerns, recruitment concerns, and administrative burdens. Sellers were also concerned about their level of net income prior to being acquired. However, the preacquisition financial concerns of sellers were not significantly stronger than the financial concerns of practices that remained independent. The environmental conditions that motivate rural physicians to sell their practices are not expected to improve. Therefore, additional sales of rural primary care practices to nonlocal buyers are expected. Further research is necessary to determine whether this shift in control will lead to changes in the quality or accessibility of care.
Wright, Nat MJ; Sheard, Laura; Tompkins, Charlotte NE; Adams, Clive E; Allgar, Victoria L; Oldham, Nicola S
Background Many drug users present to primary care requesting detoxification from illicit opiates. There are a number of detoxification agents but no recommended drug of choice. The purpose of this study is to compare buprenorphine with dihydrocodeine for detoxification from illicit opiates in primary care. Methods Open label randomised controlled trial in NHS Primary Care (General Practices), Leeds, UK. Sixty consenting adults using illicit opiates received either daily sublingual buprenorphine or daily oral dihydrocodeine. Reducing regimens for both interventions were at the discretion of prescribing doctor within a standard regimen of not more than 15 days. Primary outcome was abstinence from illicit opiates at final prescription as indicated by a urine sample. Secondary outcomes during detoxification period and at three and six months post detoxification were recorded. Results Only 23% completed the prescribed course of detoxification medication and gave a urine sample on collection of their final prescription. Risk of non-completion of detoxification was reduced if allocated buprenorphine (68% vs 88%, RR 0.58 CI 0.35–0.96, p = 0.065). A higher proportion of people allocated to buprenorphine provided a clean urine sample compared with those who received dihydrocodeine (21% vs 3%, RR 2.06 CI 1.33–3.21, p = 0.028). People allocated to buprenorphine had fewer visits to professional carers during detoxification and more were abstinent at three months (10 vs 4, RR 1.55 CI 0.96–2.52) and six months post detoxification (7 vs 3, RR 1.45 CI 0.84–2.49). Conclusion Informative randomised trials evaluating routine care within the primary care setting are possible amongst drug using populations. This small study generates unique data on commonly used treatment regimens. PMID:17210079
Turer, Christy Boling; Mehta, Megha; Durante, Richard; Wazni, Fatima; Flores, Glenn
To identify parental perspectives regarding weight-management strategies for school-age children, focus groups were conducted of parents of overweight and obese (body mass index ≥ 85th percentile) 6-12-year-old children recruited from primary-care clinics. Questions focused on the role of the primary-care provider, effective components of weight-management strategies and feasibility of specific dietary strategies. Focus groups were recorded, transcribed and analysed using margin coding and grounded theory. Six focus groups were held. The mean age (in years) for parents was 32, and for children, eight; 44% of participants were Latino, 33%, African-American and 23%, white. Parents' recommendations on the primary-care provider's role in weight management included monitoring weight, providing guidance regarding health risks and lifestyle changes, consistent follow-up and using discretion during weight discussions. Weight-management components identified as key included emphasising healthy lifestyles and enjoyment, small changes to routines and parental role modelling. Parents prefer guidance regarding healthy dietary practices rather than specific weight-loss diets, but identified principles that could enhance the acceptability of these diets. For dietary guidance to be feasible, parents recommended easy-to-follow instructions and emphasising servings over counting calories. Effective weight-management strategies identified by parents include primary-care provider engagement in weight management, simple instructions regarding healthy lifestyle changes, parental involvement and deemphasising specific weight-loss diets. These findings may prove useful in developing primary-care weight-management strategies for children that maximise parental acceptance.
Woodward, C. A.; Hutchison, B. G.; Abelson, J.; Norman, G.
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
Buckhold, Fred R
Human immunodeficiency virus (HIV) is a disease that affects 1 million patients in the United States. Many excellent drug regimens exist that effectively suppress the viral load and improve immune function, but there are consequences of long-term antiviral therapy. In addition, patients with HIV tend to have much higher rates of chronic disease, substance abuse, and cancer. Thus, while expert care in the treatment of HIV remains critical, the skill set of a primary care provider in the prevention, detection, and management of acute and chronic illness is vital to the care of the HIV patient.
Ward, Charlotte E; Morella, Lisa; Ashburner, Jeffrey M; Atlas, Steven J
Engaging physicians and practice leaders through regular performance reporting is a key goal of patient-centered medical home improvement efforts. We developed and implemented an interactive, Web-based performance dashboard for primary care practices with input from provider focus groups. Adapting a business software application, individual physician and practice-level reports included information on visit-based and panel productivity, patient panel demographics, and outcome measures (quality of care, patient experience of care, and resource utilization). User training occurred prior to dissemination. Over 2 rounds of reporting, 69% to 77% of users viewed their report within 30 days and 79% of users found the report informative.
required application of innovative and creative strategies to improve self-management. The cases are representative of some common themes within the patient with type 2 diabetes in a military primary care clinic.
de Graaf, Ireen; Onrust, Simone; Haverman, Merel; Janssens, Jan
The present study evaluated two primary care parenting interventions. First, we evaluated the most widely used Dutch practices for primary care parenting support. Second, we assessed the applicability of the Primary Care Triple P approach, which is now being utilized in a wide variety of primary care settings. Both interventions target parents of…
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
Background: 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. Methods: 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. Results: 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. Interpretation: 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. PMID:27398365
Objective: This review aims to impart information regarding recognition of obstructive sleep apnea (OSA) and associated excessive sleepiness (ES) in the primary care setting in order to provide optimal care to patients with this common but serious condition. This review will also discuss the prevalence and treatment of depression in patients with OSA. Data Sources: A MEDLINE search of articles published between 1990 and 2008 was conducted using the search terms obstructive sleep apnea AND excessive sleepiness, obstructive sleep apnea AND depression, and obstructive sleep apnea AND primary care. Searches were limited to articles in English concerned with adult patients. Study Selection: In total, 239 articles were identified. Articles concerning other sleep disorders and forms of apnea were excluded. The reference lists of identified articles were searched manually to find additional articles of interest. Data Synthesis: Primary care physicians can aid in the diagnosis of OSA and associated ES by being vigilant for lifestyle and physical risk factors associated with this condition. In addition, primary care physicians should maintain a high level of clinical suspicion when presented with illnesses that are commonly comorbid with OSA, such as psychiatric disorders and depression, in particular. Conversely, assessment of patients with OSA for common comorbidities may also improve a patient's prognosis and quality of life. Conclusions: Primary care physicians play a vital role in recognizing OSA and ES. These clinicians are crucial in supporting their patients during treatment by ensuring that they have clear, concise information regarding available therapies and the correct application and maintenance of prescribed devices. PMID:20098525
Laing, A; Marnoch, G; McKee, L; Joshi, R; Reid, J
The concept of the primary health-care team involving an increasingly diverse range of health care professionals is widely recognized as central to the pursuit of a primary care-led health service in the UK. Although GPs are formally recognized as the team leaders, there is little by way of policy prescription as to how team roles and relationships should be developed, or evidence as to how their roles have in fact evolved. Thus the notion of the primary health-care team while commonly employed, is in reality lacking definition with the current contribution of practice managers to the operation of this team being poorly understood. Focusing on the career backgrounds of practice managers, their range of responsibilities, and their involvement in innovation in general practice, presents a preliminary account of a chief scientist office-funded project examining the role being played by practice managers in primary health-care innovation. More specifically, utilizing data gained from the ongoing study, contextualizes the role played by practice managers in the primary health-care team. By exploring the business environment surrounding the NHS general practice, the research seeks to understand the evolving world of the practice manager. Drawing on questionnaire data, reinforced by qualitative data from the current interview phase, describes the role played by practice managers in differing practice contexts. This facilitates a discussion of a set of ideal type general practice organizational and managerial structures. Discusses the relationships and skills required by practice managers in each of these organizational types with reference to data gathered to date in the research.
Type 2 diabetes mellitus is a chief concern for patients, healthcare providers, and health care systems in America, and around the globe. Individuals with type 2 diabetes mellitus exhibit clinical and subclinical symptoms of anxiety more frequently than people without diabetes. Anxiety is traditionally associated with poor metabolic outcomes and increased medical complications among those with type 2 diabetes mellitus. Collaborative care models have been utilized in the multidisciplinary treatment of mental health problems and chronic disease, and have demonstrated success in managing the pathology of depression which often accompanies diabetes. However, no specific treatment model has been published that links the treatment of anxiety to the treatment of type 2 diabetes mellitus. Given the success of collaborative care models in treating depression associated with diabetes, and anxiety unrelated to chronic disease, it is possible that the collaborative care treatment of primary care patients who suffer from both anxiety and diabetes could be met with the same success. The key issue is determining how to implement and sustain these models in practice. This review summarizes the proposed link between anxiety and diabetes, and offers an innovative and evidence-based collaborative care model for anxiety and diabetes in primary care. PMID:27390262
Papanikolaou, Vicky; Zygiaris, Sotiris
Abstract Context The paper refers to the increased competition between health care providers and the need for patient‐centred services in Greece. Using service quality methodology, this paper investigates service quality perceptions of patients in Greek public primary health centres. Objective To test the internal consistency and applicability of SERVQUAL in primary health care centres in Greece. Strategy SERVQUAL was used to examine whether patients have different expectations from health care providers and whether different groups of patients may consider some dimensions of care more important than others. Results The analysis showed that there were gaps in all dimensions measured by SERVQUAL. The largest gap was detected in empathy. Further analysis showed that there were also differences depending on gender, age and education levels. A separate analysis of expectations and perceptions revealed that this gap was because of differences in patients’ perceptions rather than expectations. Discussion and conclusions This paper raises a number of issues that concern the applicability of SERVQUAL in health care services and could enhance current discussions about SERVQUAL improvement. Quality of health care needs to be redefined by encompassing multiple dimensions. Beyond a simple expectations–perceptions gap, people may hold different understandings of health care that, in turn, influence their perception of the quality of services. PMID:22296402
Suresh, Kotumachagi S; Javanaiah, Nagarathna; Shantappa, Shruti; Srivastava, Pooja
The contemporary approach to dental caries management in children focuses on prevention than treatment. Pediatricians, general dentists and pediatric dentists must be involved in a detailed preventive program, which includes prenatal counselling, treatment of expectant mothers at risk for dental caries, infant oral health care and the establishment of the dental home, so that dental disease can be prevented in infants, starting at a young age. Various health care system and organizations in India must join together to promote oral health care for all the children and specially focused toward children from disadvantaged background and children with special health care needs. How to cite this article Suresh KS, Kumar P, Javanaiah N, Shantappa S, Srivastava P. Primary Oral Health Care in India: Vision or Dream? Int J Clin Pediatr Dent 2016;9(3):228-232. PMID:27843255
Gordon, James A
Technology-enhanced patient simulation has emerged as an important new modality for teaching and learning in medicine. In particular, immersive simulation platforms that replicate the clinical environment promise to revolutionize medical education by enabling an enhanced level of safety, standardization, and efficiency across health-care training. Such an experiential approach seems unique in reliably catalyzing a level of emotional engagement that fosters immediate and indelible learning and allows for increasingly reliable levels of performance evaluation-all in a completely risk-free environment. As such, medical simulation is poised to emerge as a critical component of training and certification throughout health care, promising to fundamentally enhance quality and safety across disciplines. To encourage routine simulation-based practice as part of its core quality and safety mission, Massachusetts General Hospital now incorporates simulation resources within its historic medical library (est. 1847), located at the center of the campus. In this new model, learners go to the library not only to read about a patient's illness, but also to take care of their "patient." Such an approach redefines and advances the central role of the library on the campus and ensures that simulation-based practice is centrally available as part of everyday hospital operations. This article describes the reasons for identifying simulation as an institutional priority leading up to the Massachusetts General Hospital Bicentennial Celebration (1811-2011) and for creating a simulation-based learning laboratory within a hospital library.
Nurses wishing to find out more about the new English primary care organisations, but looking for an easier read than Trust in Experience, may find that The Primary Care Trust Handbook, edited by Peter Smith, will meet their needs. Although repetitive in some areas, The Primary Care Trust Handbook does provide the reader with a condensed overview of the shift which has taken place in healthcare policy, the emergence of primary care trusts, and the issues that face these new organisations.
Thomas, Ralph; Cook, Alan; Main, Gavin; Taylor, Tom; Caruana, Elizabeth Galizia; Swingler, Robert
Background The diagnostic yield of neuroimaging in chronic headache is low, but can reduce the use of health services. Aim To determine whether primary care access to brain computed tomography (CT) referral for chronic headache reduces referral to secondary care. Design of study Prospective observational analysis of GP referrals to an open access CT brain scanning service. Setting Primary care, and outpatient radiology and neurology departments. Method GPs in Tayside and North East Fife, Scotland were given access to brain CT for patients with chronic headache. All referrals were analysed prospectively over 1 year, and questionnaires were sent to referrers to establish whether imaging had resulted in or stopped a referral to secondary care. The Tayside outpatient clinic database identified scanned patients referred to the neurology clinic for headache from the start of the study period to at least 1 year after their scan. Results There were 232 referrals (55.1/100 000/year, 95% confidence interval = 50.4 to 59.9) from GPs in 59 (82%) of 72 primary care practices. CT was performed on 215 patients. Significant abnormalities were noted in 3 (1.4%) patients; there were 22 (10.2%) non-significant findings, and 190 (88.4%) normal scans. Questionnaires of the referring GPs reported that 167 (88%) scans stopped a referral to secondary care. GPs referred 30 (14%) scanned patients to a neurologist because of headache. It is estimated that imaging reduced referrals to secondary care by 86% in the follow-up period. Conclusion An open access brain CT service for patients with chronic headache was used by most GP practices in Tayside, and reduced the number of referrals to secondary care. PMID:20529496
Hospital checklists are gaining momentum, particularly since the World Health Organization's Safe Surgery Saves Lives Program published results of its study in 2009, indicating that a safety checklist significantly improved surgical outcomes in hospitals across the world. The South Carolina Hospital Association, in partnership with Dr Atul Gawande, has launched a program to implement the World Health Organization Surgical Safety Checklist in every operating room in the state over the next few years. Governments, in such places as France and the Canadian province of Ontario, are also stepping in to make surgical checklists mandatory in their hospitals. Drawing on research, recent initiatives, and the company's experience in high-acuity units, this article explores the implications and challenges of implementing checklists in today's hospitals. If a checklist is to succeed as a mechanism for transforming evidence-based care and safety protocols into best and actual practice, it needs to be used consistently and durably; to achieve this, hospitals need to foster a supportive environment as well as acquire a system to monitor, measure, and manage a culture that effectively embraces checklists.
Martin, Graham P; Weaver, Simon; Currie, Graeme; Finn, Rachael; McDonald, Ruth
The need for organizational innovation as a means of improving health-care quality and containing costs is widely recognized, but while a growing body of research has improved knowledge of implementation, very little has considered the challenges involved in sustaining change - especially organizational change led 'bottom-up' by frontline clinicians. This study addresses this lacuna, taking a longitudinal, qualitative case-study approach to understanding the paths to sustainability of four organizational innovations. It highlights the importance of the interaction between organizational context, nature of the innovation and strategies deployed in achieving sustainability. It discusses how positional influence of service leads, complexity of innovation, networks of support, embedding in existing systems, and proactive responses to changing circumstances can interact to sustain change. In the absence of cast-iron evidence of effectiveness, wider notions of value may be successfully invoked to sustain innovation. Sustainability requires continuing effort through time, rather than representing a final state to be achieved. Our study offers new insights into the process of sustainability of organizational change, and elucidates the complement of strategies needed to make bottom-up change last in challenging contexts replete with competing priorities.
Booth, Mark; Hill, Graham; Moore, Michael J; Dalla, Danielle; Moore, Michael G; Messenger, Anne
On 1 July 2015, the Australian Government established 31 new Primary Health Networks (PHNs), following a review by its former Chief Medical Officer, John Horvath, of 61 Medicare Locals created under the previous Labor administration. The Horvath review recommended, among other things, that new, larger primary health organisations be established to reduce fragmentation of care by integrating and coordinating health services, supporting the role of general practice, and leveraging and administering health program funding. The two main objectives of the new PHNs, as stated on the Department of Health's website, are "increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes, and improving coordination of care to ensure patients receive the right care in the right place at the right time". Below are three viewpoints, commissioned for this primary health care themed issue of Public Health Research & Practice, from the Australian Government Department of Health, the Public Health Association of Australia and a Sydney-based PHN. We asked the authors to focus particularly on how the newly established networks might help to integrate public health within the primary health care landscape. Our authors have pointed out the huge overlap between public health and primary care and looked at evidence showing the great benefits for health systems of collaboration between the two. Challenges ahead include a possible government focus on delivery of 'frontline' medical services, which may come at the expense of population health, and the complexity of dealing with all primary health care stakeholders, including health professionals, Local Health Districts, nongovernment organisations, research institutions and local communities.
... 42 Public Health 4 2010-10-01 2010-10-01 false Primary care case management services. 440.168 Section 440.168 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: GENERAL PROVISIONS Definitions § 440.168...
Aysola, Jaya; Groves, DaShawn; Hicks, LeRoi S
Background Current policy promotes health center professional training and pipeline programs as solutions to bolster primary care workforce in shortage areas, despite the paucity of evidence. Methods We analyzed data from US health centers we surveyed from March to June 2010, merged with federal health center data, to estimate associations between health center training and pipeline programs and provider recruitment and retention. Results Of the 976 surveyed, 391 health centers responded. Health centers with career ladder programs compared to those without had higher adjusted rates of no/minimal difficulty in recruitment of primary care providers. (17.6% vs. 10.6%; p=.01) and close to double the adjusted rates of reporting no/minimal difficulty in retention of primary care providers (39.4% vs. 21.2%; p=.0001). Discussion There remains a need for further evaluation of health professional programs in order to expand models, such as career ladder programs, that demonstrate effectiveness in improving the primary care workforce in shortage areas. PMID:27891532
Atkin, Kathryn; Beal, Margaret W; Long-Middleton, Ellen; Roncari, Danielle
Long-acting reversible contraceptive (LARC) methods are underutilized in the adolescent population despite their superior efficacy over non-LARC methods. The purpose of this article is to discuss the barriers that lead to underutilization of these methods and present an evidence-based approach for the use of LARC methods among adolescents in the primary care setting.
day retention in knowledge and comfort with PTSD-related skills, we did not assess for long - term impact of the training, nor did we audit 13...SUBJECT TERMS Posttraumatic stress disorder, primary care, web-based training, medical education 16. SECURITY CLASSIFICATION OF: 17. LIMITATION...Eligible participants were English -speaking PCPs, including licensed physicians (internists, family practitioners, pediatricians), nurse practitioners
Reisman, A; Duran, L
A time-honored industrial engineering technique, job evaluation, which was developed to set rates for manual labor, was used in the design of new teams for delivering primary health care in Latin America. The technique was used both in writing job descriptions for new allied health personnel and in designing the curriculums needed to train the personnel. PMID:6856744
The aim of this dissertation study was to identify and describe the use of electronic health records (EHRs) for information sharing between patients and clinicians in primary-care encounters and to understand work system factors influencing information sharing. Ultimately, this will promote better design of EHR technologies and effective training…
Tatar, M; Tatar, F
The Alma-Ata Declaration has long been regarded as a watershed in the health policy arena. The global goal of the World Health Organization, 'Health for All by the Year 2000' through primary health care, has attracted many countries both in the developed and the developing world and commitments to this end have been made at every level. However, albeit this consensus on the paper, a common and explicit definition of the concept has not been reached yet. This paper aims at discussing various definitions of primary health care that emerged after the Declaration and also presenting a case study from Turkey, a country that advocates primary health care in her recent health policy reform attempts. After setting the conceptual framework for discussion the Turkish case is presented by using research carried out among Turkish policy-makers at different levels of the State apparatus. It has been concluded that application of primary health care principles as defined in the broad definition of the concept requires major changes or rather shake-ups in Turkey. These areas are outlined briefly at the end of the paper.
Gum, Amber M.; Arean, Patricia A.; Hunkeler, Enid; Tang, Lingqi; Katon, Wayne; Hitchcock, Polly; Steffens, David C.; Dickens, Jeanne; Unutzer, Jurgen
Purpose: For depressed older primary care patients, this study aimed to examine (a) characteristics associated with depression treatment preferences; (b) predictors of receiving preferred treatment; and (c) whether receiving preferred treatment predicted satisfaction and depression outcomes. Design and Methods: Data are from 1,602 depressed older…
Gardner, Katy; Taylor, William; Marks, Eileen; Goodson, Nicola
Background Over recent years there has been increased interest in the disease burden associated with vitamin D deficiency. This, combined with recognition that the prevalence of vitamin D deficiency is high in the UK, has led to increased requests for vitamin D assessment from primary care clinicians. Setting A primary care cohort in Liverpool. Question How has the usefulness of vitamin D testing changed over time in identifying deficiency? Methods Vitamin D results from primary care practices in Liverpool were collected between 2007 and 2012, inclusive. Results were allocated to six cohorts based on year of request and each was grouped into three categories (adequate, insufficient and deficient). Results Vitamin D results of 9460 (74%) first tests and 3263 (26%) retests were analysed. Total number of requests increased 11-fold, from 503 in 2007 to 5552 in 2012. Overall 42% of first-test results were deficient (< 30 nmol). With each incremental year, more cases of vitamin D deficiency were detected – but the odds of detecting vitamin D deficiency decreased. Conclusions An exponential increase in the number of vitamin D requests was observed over this six-year period. Although more patients with vitamin deficiency were identified, the increased number of tests represents a significant cost to health services. Moreover, the practice of retesting too soon after treatment can be inappropriate. There is a need to develop clear guidance for assessing vitamin D status in primary care. PMID:26217398
This book is intended to assist teachers, practitioners, and administrators to develop programs for training nonphysician, primary health care workers in Third World countries. It contains the instructional context of a comprehensive training program, organized into chapters and presented in outline form. Learning strategies follow each section of…
Singh, Ranjit; Singh, Ashok; Servoss, Timothy J.; Singh, Gurdev
Context: Rural primary care is a complex environment in which multiple patient safety challenges can arise. To make progress in improving safety with limited resources, each practice needs to identify those safety problems that pose the greatest threat to patients and focus efforts on these. Purpose: To describe and field-test a novel approach to…
Slaby, Andrew E.; And Others
The pattern of use of psychiatry over a 12-month period in a university-based primary care center is reported. Interest in pursuing careers in family practice and amount of time spent in the center were related to seeking consultation. Differences in use by nurse practitioners, social workers, and patients are cited. ( Author/LBH)
Katz, D L
The leading causes of death in the United States are predominantly attributable to modifiable behaviors. Patients with behavioral risk factors for premature death and disability, including dietary practices; sexual practices; level of physical activity; motor vehi cle use patterns; and tobacco, alcohol, and illicit sub stance use, are seen far more consistently by primary care providers than by mental health specialists. Yet models of behavior modification are reported, debated, and revised almost exclusively in the psychology literature. While the Stages of Change Model, or Transtheo retical Model, has won application in a broadening array of clinical settings, its application in the primary care setting is apparently quite limited despite evidence of its utility [Prochaska J, Velicer W. Am J Health Promot 1997;12:38-48]. The lack of a rigorous behavioral model developed for application in the primary care setting is an impediment to the accomplishment of public health goals specified in the Healthy People objectives and in the reports of the U.S. Preventive Services Task Force. The Pressure System Model reported here synthesizes elements of established behavior modification theories for specific application under the constraints of the primary care setting. Use of the model in both clinical and research settings, with outcome evaluation, is encouraged as part of an effort to advance public health.
This qualitative study focused on counseling psychology doctoral students' perspectives regarding their practicum training experience in primary care psychology. The four participants included three females and one male. Semi-structured individual and focus group interviews were used to explore participants' experiences. The participants described…
Fordwood, Samantha R.; Asarnow, Joan R.; Huizar, Diana P.; Reise, Steven P.
Although depression is strongly associated with suicide attempts and suicide deaths, most depressed youth do not make an attempt, indicating the need to identify additional risk factors. We examined suicide attempts among 451 depressed primary care patients, 13 to 21 years of age. In bivariate analyses, youth classified as suicide attempters…
McGregor, Jessina C.; Bearden, David T.; Townes, John M.; Sharp, Susan E.; Gorman, Paul N.; Elman, Miriam R.; Mori, Motomi; Smith, David H.
To support antimicrobial stewardship, some healthcare systems have begun creating outpatient antibiograms. We developed inpatient and primary care outpatient antibiograms for a regional health maintenance organization (HMO) and academic healthcare system (AHS). Antimicrobial susceptibilities from 16,428 Enterococcus, Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa cultures from 2010 were summarized and compared. Methicillin susceptibility among S. aureus was similar in inpatients and primary care outpatients (HMO: 61.2% vs. 61.9%, p=0.951; AHS: 62.9% vs. 63.3%, p>0.999). E. coli susceptibility to trimethoprim/sulfamethoxazole was also similar (HMO: 81.8% vs. 83.6%, p=0.328; AHS: 77.2% vs. 80.9%, p=0.192), but ciprofloxacin susceptibility differed (HMO: 88.9% vs. 94.6%, p<0.001; AHS: 81.2% vs. 90.6%, p<0.001). In the HMO, ciprofloxacin-susceptible P. aeruginosa were more frequent in primary care outpatients than inpatients (91.4% vs. 79.0%, p=0.007). Comparison of cumulative susceptibilities across settings yielded no consistent patterns; therefore, outpatient primary care antibiograms may more accurately inform prudent empiric antibiotic prescribing. PMID:23541690
Chiauzzi, Emil; Trudeau, Kimberlee J.; Zacharoff, Kevin; Bond, Kathleen
Introduction: Primary care physicians (PCPs) treat a high proportion of chronic pain patients but often lack training about how to assess and address issues associated with prescribing opioids when they are an appropriate component of therapy. The result may be that they may avoid treating these patients, which can lead to an undertreatment of…
Maher, Stacia; Lopez, Patricia; McKee, M. Diane; Deen, Darwin; Fornari, Alice; Fletcher, Jason; Blank, Arthur
Purpose: The paper aims to evaluate a primary care obesity prevention intervention, targeting low-income minority parents in the USA. The first objective is to describe the barriers to behavior change experienced by families. The second objective is to understand the types of strategies that were used by the health educator to empower families to…
Zweig, Richard A.; Siegel, Lawrence; Hahn, Steven; Kuslansky, Gail; Byrne, Kathy; Fyffe, Denise; Passman, Vicki; Stewart, Douglas; Hinrichsen, Gregory
Most older adults diagnosed with a mental disorder receive treatment in primary care settings that lack personnel skilled in geropsychological diagnosis and treatment. The Ferkauf Older Adult Program of Yeshiva University endeavors to bridge this gap by providing training in geriatric psychology, through coursework and diverse clinical practica,…
Century, Gillian; Leavey, Gerard; Payne, Helen
The provision of counselling services for refugee and asylum-seeking patients is relatively new in the UK and their complex needs may present considerable challenges within primary care, where access to specialist support resources is often limited. As far as we know, no previous research has attempted to look at the experiences of the counsellors…
Pediatric primary care provides an enormous window of opportunity to offer families information and support on their child's social-emotional well-being and on their growth as a family in a nonstigmatizing environment. With new technology, such as the Internet, and advances in the scientific study of early childhood development, parents face an…
Clare, F. Lawrence, Comp.; And Others
A bibliography on education of physicians for primary care is presented, based on a search of the "Index Medicus" primarily for the period 1971-1983. Selected articles from 1984 are also included. The approximately 60 references are listed alphabetically by the lead author's surname. A major feature of the bibliography is the keywording of each…
Shell, Renee; Tudiver, Fred
Rural Appalachia has significantly higher overall cancer mortality compared with national rates, and lack of cancer screening is believed to be one of the contributing factors. Reducing the cancer disparity in this region must include strategies to address suboptimal cancer screening practices by rural Appalachian primary care providers (PCPs). To…
Parchman, Michael L.; Von Korff, Michael; Baldwin, Laura-Mae; Stephens, Mark; Ike, Brooke; Cromp, DeAnn; Hsu, Clarissa; Wagner, Ed H.
Background The challenge of responding to prescription opioid overuse within the United States has fallen disproportionately on the primary care clinic setting. Here we describe a framework comprised of 6 Building Blocks to guide efforts within this setting to address the use of opioids for chronic pain. Methods Investigators conducted site visits to thirty primary care clinics across the United States selected for their use of team-based workforce innovations. Site visits included interviews with leadership, clinic tours, observations of clinic processes and team meetings, and interviews with staff and clinicians. Data were reviewed to identify common attributes of clinic system changes around chronic opioid therapy (COT) management. These concepts were reviewed to develop narrative descriptions of key components of changes made to improve COT use. Results Twenty of the thirty sites had addressed improvements in COT prescribing. Across these sites a common set of 6 Building Blocks were identified: 1) providing leadership support; 2) revising and aligning clinic policies, patient agreements (contracts) and workflows; 3) implementing a registry tracking system; 4) conducting planned, patient-centered visits; 5) identifying resources for complex patients; and 6) measuring progress toward achieving clinic objectives. Common components of clinic policies, patient agreements and data tracked in registries to assess progress are described. Conclusions In response to prescription opioid overuse and the resulting epidemic of overdose and addiction, primary care clinics are making improvements driven by a common set of best practices that address complex challenges of managing COT patients in primary care settings. PMID:28062816
Glasgow, Michael S.
Describes the use of integrated modular teaching of the human biology component of the Health Associate Program at Johns Hopkins University, where the goal is to develop an understanding of the sciences as applied to primary care. Discussion covers the module sequence, the human biology faculty, goals of the human biology faculty, laboratory…
Elmore, James L.
Dissociative disorders have a lifetime prevalence of about 10%. Dissociative symptoms may occur in acute stress disorder, posttraumatic stress disorder, somatization disorder, substance abuse, trance and possession trance, Ganser's syndrome, and dissociative identity disorder, as well as in mood disorders, psychoses, and personality disorders. Dissociative symptoms and disorders are observed frequently among patients attending our rural South Carolina community mental health center. Given the prevalence of mental illness in primary care settings and the diagnostic difficulties encountered with dissociative disorders, such illness may be undiagnosed or misdiagnosed in primary care settings. We developed an intervention model that may be applicable to primary care settings or helpful to primary care physicians. Key points of the intervention are identification of dissociative symptoms, patient and family education, review of the origin of the symptoms as a method of coping with trauma, and supportive reinforcement of cognitive and relaxation skills during follow-up visits. Symptom recognition, Education of the family, Learning new skills, and Follow-up may be remembered by the mnemonic device SELF. We present several cases to illustrate dissociative symptoms and our intervention. Physicians and other professionals using the 4 steps and behavioral approaches will be able to better recognize and triage patients with dissociative symptoms. Behaviors previously thought to be secondary to psychosis or personality disorders may be seen in a new frame of reference, strengthening the therapeutic alliance while reducing distress and acting-out behaviors. PMID:15014580
Thompson, Megan R.; Stone, Ramona F.; Ochs, V. Dan; Litvan, Irene
In order to determine primary health care providers' (PCPs) knowledge gaps on Parkinson's disease, data were collected before and after a one-hour continuing medical education (CME) lecture on early Parkinson's disease recognition and treatment from a sample of 104 PCPs participating at an annual meeting. The main outcome measure was the…
Lind, April; Richter, Sara; Craft, Cheryl; Shapiro, Alice C
Objectives Postpartum depression (PPD) affects approximately 10-20% of all mothers after giving birth. Adequate screening and follow-up care for the postpartum mother with depression is an essential component of quality care in this population. The purpose of this quality improvement project was to evaluate the quality and quantity of a postnatal PPD screening program and the subsequent initiation of needed PPD treatment in an integrated health system. Methods After implementing a standardized PPD screening process, we conducted an 18-month retrospective study of patient visits that required a PPD screen. Data were abstracted from medical records and analyzed to determine if postnatal PPD screening occurred, what quality of the screening was, and what follow-up measures were taken. Results Within the study timeframe, 28,389 postpartum and well-child visits were eligible for PPD screening. PPD screening occurred at 88% of eligible visits for approximately 5000 unique women. PPD was identified in 8.1% of screened women. Conclusions Of women with PPD, at least 44.8% were prescribed an SSRI and 21.4% attended a visit with a mental health professional, which is consistent with other studies. Screening can be successful through collaboration, although ongoing evaluation and process modification are necessary.
Jung, Woonggyu; Kim, Jeehyun; Jeon, Mansik; Chaney, Eric J; Stewart, Charles N; Boppart, Stephen A
The goal of this study is to develop an advanced point-of-care diagnostic instrument for use in a primary care office using handheld optical coherence tomography (OCT). This system has the potential to enable earlier detection of diseases and accurate image-based diagnostics. Our system was designed to be compact, portable, user-friendly, and fast, making it well suited for the primary care office setting. The unique feature of our system is a versatile handheld OCT imaging scanner which consists of a pair of computer-controlled galvanometer-mounted mirrors, interchangeable lens mounts, and miniaturized video camera. This handheld scanner has the capability to guide the physician in real time for finding suspicious regions to be imaged by OCT. In order to evaluate the performance and use of the handheld OCT scanner, the anterior chamber of a rat eye and in vivo human retina, cornea, skin, and tympanic membrane were imaged. Based on this feasibility study, we believe that this new type of handheld OCT device and system has the potential to be an efficient point-of-care imaging tool in primary care medicine.
Valdiserri, Ronald O; Nazi, Kim; McInnes, D Keith; Ross, David; Kinsinger, Linda
Late diagnosis of HIV infection contributes to poor medical outcomes and helps sustain continued transmission of virus. Published evidence suggests that despite current public health recommendations, patients receiving care in the Veterans Health Administration (VHA) system are not being routinely tested for HIV infection. Using a sample of computer-literate veterans, we conducted a survey of recent testing experiences. My HealtheVet (MHV) is a secure website allowing registered Veterans to access limited personal VHA health information. Using the American Customer Satisfaction Index (ACSI) Survey, an electronic questionnaire on "health screening" was conducted in late Fall/early winter 2008-2009. A random sample (4%) of MHV users were surveyed; approximately 17% completed the survey and responses ranged from 31,237 to 33,074. Only 9% of the respondents indicated that they had been offered a test for HIV in the last 12 months compared to 83% who had been offered cholesterol screening, 65% blood sugar screening and 19% who had been offered testing for Hepatitis C virus (HCV). Of those who had been offered HIV testing, 91% indicated that they'd had the test performed. Of note, the percentage of respondents who indicated that they would "very likely" accept a test, if offered, was similar for HIV (73%), HCV (79%), cholesterol (75%), and blood sugar (75%). Although these results cannot be generalized to all Veterans in care, they suggest that routine testing for HIV has not been taking place and support recent VHA policy changes to remove barriers to HIV testing.
Nathanson, P; Noether, M; Ozminkowski, R J; Smith, K M; Raney, B E; Mickey, D; Hawley, P M
An insurance claims databased profiling system was developed to help select new primary care physicians (PCPs) for a managed care network. PCPs (family practitioners, internists, and pediatricians) were ranked based on how closely their actual use of outpatient services conformed to the predictions of a mathematical model that adjusted for differences in age, sex, and case mix.
Beaulac, Julie; Edwards, Jeanette; Steele, Angus
Aim To investigate the implementation and initial impact of the Physician Integrated Network (PIN) mental health indicators, which are specific to screening and managing follow-up for depression, in three primary care practices with Shared Mental Health Care in Manitoba.
Tudiver, Fred; Wolff, L. Thomas; Morin, Philip C.; Teresi, Jeanne; Palmas, Walter; Starren, Justin; Shea, Steven; Weinstock, Ruth S.
Context: Few telemedicine projects have systematically examined provider satisfaction and attitudes. Purpose: To determine the acceptability and perceived impact on primary care providers' (PCP) practices of a randomized clinical trial of the use of telemedicine to electronically deliver health care services to Medicare patients with diabetes in…
Giraldo Osorio, Alexandra; Vélez Álvarez, Consuelo
A development process, marked by the re-appearance of the primary health care as the core of health systems, has emerged in Latin America. Governments have made a commitment to renew this strategy as the basis of their health systems. However, these health systems are mainly faced with re-introducing equity values, and there are common challenges such as providing the health systems with trained human resources in sufficient numbers, overcoming the fragmentation/segmentation of the systems, ensuring financial sustainability, improving governance, quality of care and information systems, expanding coverage, preparing to face the consequences of an aging population, the changing epidemiological profile, and increase in the response capacity of the public health system. This article is intended to provide a comprehensive view of the progress and challenges of the inclusion of primary care health systems in Latin American countries.
Lewis, Eleanor T; Trafton, Jodie A
Pain is one of the most common reasons that patients seek treatment from health care professionals, often their primary care providers. One tool for treating pain is opioid therapy, and opioid prescriptions have increased dramatically in recent years in the United States. This article will review recent research about opioids that is most relevant to treating chronic pain in the context of a typical primary care practice. It will focus on four key practices that providers can engage in before and during the course of opioid therapy that we believe will enhance the likelihood that opioids, when used, are an effective tool for pain management: avoiding sole reliance on opioids; using adequate opioid doses to address pain; mitigating the risk of opioid misuse by patients; and fostering collaborative relationships for treating complex patients.
Mamtani, Ravinder; Stern, Penny; Dawood, Ismail; Cheema, Sohaila
Metals are an important and essential part of our daily lives. Their ubiquitous presence and use has not been without significant consequences. Both industrial and nonindustrial exposures to metals are characterized by a variety of acute and chronic ailments. Underreporting of illnesses related to occupational and environmental exposures to chemicals including metals is of concern and presents a serious challenge. Many primary care workers rarely consider occupational and environmental exposures to chemicals in their clinical evaluation. Their knowledge and training in the evaluation of health problems related to such exposures is inadequate. This paper presents documented research findings from various studies that have examined the relationship between metal exposures and their adverse health effects both in developing and developed countries. Further, it provides some guidance on essential elements of a basic occupational and environmental evaluation to health care workers in primary care situations. PMID:22007209
Arnold, Corey W.; Oh, Andrea; Chen, Shawn; Speier, William
Background and Objective Probabilistic topic models provide an unsupervised method for analyzing unstructured text. These models discover semantically coherent combinations of words (topics) that could be integrated in a clinical automatic summarization system for primary care physicians performing chart review. However, the human interpretability of topics discovered from clinical reports is unknown. Our objective is to assess the coherence of topics and their ability to represent the contents of clinical reports from a primary care physician’s point of view. Methods Three latent Dirichlet allocation models (50 topics, 100 topics, and 150 topics) were fit to a large collection of clinical reports. Topics were manually evaluated by primary care physicians and graduate students. Wilcoxon Signed-Rank Tests for Paired Samples were used to evaluate differences between different topic models, while differences in performance between students and primary care physicians (PCPs) were tested using Mann-Whitney U tests for each of the tasks. Results While the 150-topic model produced the best log likelihood, participants were most accurate at identifying words that did not belong in topics learned by the 100-topic model, suggesting that 100 topics provides better relative granularity of discovered semantic themes for the data set used in this study. Models were comparable in their ability to represent the contents of documents. Primary care physicians significantly outperformed students in both tasks. Conclusion This work establishes a baseline of interpretability for topic models trained with clinical reports, and provides insights on the appropriateness of using topic models for informatics applications. Our results indicate that PCPs find discovered topics more coherent and representative of clinical reports relative to students, warranting further research into their use for automatic summarization. PMID:26614020
Huenges, Bert; Gulich, Markus; Böhme, Klaus; Fehr, Folkert; Streitlein-Böhme, Irmgard; Rüttermann, Viktor; Baum, Erika; Niebling, Wilhelm-Bernhard; Rusche, Herbert
During their studies to become medical professionals, all students are obliged to become familiar with various aspects of primary care. The aim is to provide all students with a high quality training which ensures the best possible cooperation across all sectors of the medical system. Primary care comprises the primary use of the medical service by an unfiltered set of patients as well as continued patient care – including home-care. This position paper was developed together with representatives of the German Society of University Teachers of General Practice (GHA), the German Society for Ambulatory General Paediatrics (DGAAP), the German Society of General Practice and Family Medicine (DEGAM) and the German Society for Internal Medicine (DGIM). It includes recommendations for teaching in the field of primary care in four different types of internships such as preclinical work experience (“Hospitation”), 4-week clinical traineeships of a casual nature (“Famulatur”) and 2-week courses of structured and assessed clinical training (“Blockpraktikum”) as well as a broad-based 4-month elective clinical placement in the final year (known as a practical year, “PJ”). The recommendations encompass structural and process criteria for internships in different general practices. In addition, for the first time recommendations for teaching on campus – in the fields of general medicine, paediatrics, numerous cross-sectional areas and other clinical fields, but also for clinical skills training – are set down here. In this position paper the intention is to demonstrate the possible ways in which more aspects of primary care could be integrated into undergraduate medical training. PMID:25228937
Osborn, E H; O'Neil, E H
The authors studied four "bimodal" medical schools--those ranked in the top 20% by the Association of American Medical Colleges both in production of primary care physicians and in receiving research grants from the National Institutes of Health. A descriptive, anthropologic method was used to describe the cultures of these schools and to determine common factors in their success. The four schools are at the University of Washington, the University of North Carolina, the University of California, San Francisco, and the University of California, San Diego. These common factors ranged from characteristics of the schools to characteristics of their external environments. All four are part of large, state-supported universities. They are relatively new schools in areas of the country that have blossomed in biotechnology, aerospace, and computer industries. The schools' missions, admission committees, and educational programs reflect their dual role: to meet the health care needs of their states and to advance basic science knowledge in medicine. Each state has a strong Academy of Family Practice, and the medical schools have been in the forefront of residency training in this specialty. Federal- and state-funded Area Health Education Centers and private foundations have provided seed money for educational programs in community and rural settings that attract medical students to primary care. Research-intensive medical schools can encourage students to enter primary care specialties if they have strong primary care leaders and programs and if they support medical education programs outside the academic, tertiary-care center. A culture of mutual respect and commitment to community service is also essential to achieving this bimodal success.
Eidus, Robert; Pace, Wilson D; Staton, Elizabeth W
Common "quality" metrics may represent the quality of care for large populations; however, they do not adequately represent quality in individual primary care settings, especially as stand-alone indices. Using discreet threshold values to measure quality in primary care may result in physicians focusing on managing patients by the numbers at the expense of making individualized and nuanced clinical decisions. Current performance measures may be misapplied as proxies for both cost savings and quality. We posit that developing and focusing measurement on high-leverage activities will yield better clinical outcomes and potentially lower cost. As a starting point for further work in this area, we suggest the development of metrics that track identification and management of depression; management of transitions of care; care coordination; team-based care; identification and support of socially frail/isolated individuals; pharmacologic management, including optimizing medication and dealing with adherence issues; and establishment of a therapeutic environment. These processes, or others like them, will require infrastructure that may be costly and time-consuming, and measuring these processes will require thought and effort. Nevertheless, we believe developing metrics based on high-leverage activities will yield greater clinical and economic returns than relying on the metrics currently in place.
Young, Charlotte E; Mutch, Allyson J; Boyle, Frances M; Dean, Julie H
While chronic disease places an increasing burden on Australia's primary care system it is unrealistic to expect GPs to meet the range of support needs experienced by patients managing chronic conditions. Consumer health organisations (CHO) have the potential to augment clinical care by providing a variety of supportive services; however, they are underutilised by patients and GPs. This qualitative study investigates GPs' knowledge and perceptions of CHO and their contributions to chronic disease care. The study involved semi-structured interviews with 10 GPs. Overall, participants demonstrated clear understanding of the role of CHO in chronic disease management, but a critical finding was the way GPs' view of their own chronic care role appears to influence referral practices. GPs operating in a traditional role were less likely to refer to CHO than those who had adopted a chronic care approach. A second key finding related to GPs' views of Diabetes Australia. All GPs identified this organisation as an important referral point, providing some reassurance that CHO can be integrated into the primary care sector. Further research is needed to determine how the 'definite advantages' associated with Diabetes Australia can be used to extend GP referral and enhance the health system's integration of other CHO.
Moreno-Peral, Patricia; Conejo-Cerón, Sonia; Fernández, Ana; Berenguera, Anna; Martínez-Andrés, María; Pons-Vigués, Mariona; Motrico, Emma; Rodríguez-Martín, Beatriz; Bellón, Juan A.; Rubio-Valera, Maria
Background Primary care (PC) patients have difficulties in committing to and incorporating primary prevention and health promotion (PP&HP) activities into their long-term care. We aimed to re-interpret, for the first time, qualitative findings regarding factors affecting PC patients' acceptance of PP&HP activities. Methods and Findings A meta-ethnographic synthesis was generated following electronic and manual searches that retrieved 29 articles. Papers were reviewed and translated to produce a re-interpretation of the extracted concepts. The factors affecting PC patients' receptiveness to PP&HP activities were framed in a four-level ecological model (intrapersonal, interpersonal, institutional and environment and society). Intrapersonal factors (patients' beliefs/attitudes, knowledge, skills, self-concept, motivation and resources) were the most numerous, with almost 25 different factors. Public health education to modify erroneous beliefs and values regarding PP&HP could encourage a transition to healthier lifestyles. Health care professionals' abilities to communicate and involve patients in the decision-making process can act as facilitators. Biopsychosocial training (with emphasis on communication skills) for health professionals must start with undergraduates. Increased consultation time, the use of reminders, follow-up visits and tools for communicating risk and motivating patients could be applied at the intrapersonal level. Collaborative care involving other health professionals (nutritionists or psychotherapists) and family and community stakeholders (teachers or gym trainers) was important in developing healthier habits. Patients also cited barriers related to the built environment and socioeconomic difficulties that highlighted the need for policies promoting social justice and equity. Encouraging PP&HP using social marketing strategies and regulating media to control its impact on health were also cited. Only the perspectives of PC patients in the
Staples, Lauren G.; Fogliati, Vincent J.; Dear, Blake F.; Nielssen, Olav
Background The Wellbeing Plus Course is an internet-delivered psychological intervention for older adults with anxiety or depression. Aims To compare the effectiveness of the Wellbeing Plus Course in a public health setting (clinic group) with its efficacy in a randomised controlled trial (research group). Method Participants (n=949) were Australian adults aged 60 and above. Primary outcome measures were the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder scale (GAD-7). Results Initial symptom severity was higher in the clinic group and course completion was lower. Both groups showed significant symptom reductions at post-treatment and were satisfied with the treatment. Results were maintained at 3-month follow-up. Within-group symptom changes were comparable between settings; there were no between-group differences on primary outcomes or satisfaction. Conclusions The Wellbeing Plus Course is as effective and acceptable in routine clinical care, as it is in controlled research trials. Declaration of interest N.T. and B.F.D developed the Wellbeing Plus Course but derived no financial benefit from it. Copyright and usage © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license. PMID:27703794
Sullivan, Patrick S; Rothman, Richard E; Brown, Emily H; Fitzpatrick, Lisa K; Wood, Angela F; Hernandez, Paloma I; Nunn, Amy S; Serota, Martin L; Moreno-Walton, Lisa
Background The United States health care system remains far from implementing the Centers for Disease Control and Prevention's recommendation of routine human immunodeficiency virus (HIV) screening as part of health care for adults. Although consensus for the importance of screening has grown, innovations in implementing routine screening are still lacking. HIV on the Frontlines of Communities in the United States (FOCUS) was launched in 2010 to provide an environment for testing innovative approaches to routine HIV screening and linkage to care. Objective The strategy of the FOCUS program was to develop models that maximize the use of information systems, fully integrate HIV screening into clinical practice, transform basic perceptions about routine HIV screening, and capitalize on emerging technologies in health care settings and laboratories. Methods In 10 of the most highly impacted cities, the FOCUS program supports 153 partnerships to increase routine HIV screening in clinical and community settings. Results From program launch in 2010 through October 2013, the partnerships have resulted in a total of 799,573 HIV tests and 0.68% (5425/799,573) tested positive. Conclusions The FOCUS program is a unique model that will identify best practices for HIV screening and linkage to care. PMID:25093431
Williams, Mark A; Kaminsky, Leonard A
There is unquestioned value of the need to incorporate Healthy Lifestyle Medicine (HLM) within the traditional models of healthcare. Primary care providers are well positioned to implement HLM as a routine aspect of their healthcare practice. Unfortunately, barriers for this to occur, including poor professional training in the components of HLM and limitations in the time they have available to spend with patients, result in inadequate delivery of HLM from primary care providers. Thus, new approaches for the delivery of HLM need to be developed that would allow primary care providers better, and more, opportunities to make patient referrals. Ideally, this would start with creating a culture change within communities that embraces the importance on living a healthy lifestyle. One opportunity which should be considered is expanding access to currently available options, such as cardiac rehabilitation programs and worksite wellness programs. Both types of programs already provide key elements of HLM within their existing structure. However, new models also need to be developed. Community-based HL centers comprising HL specialists including counselors, exercise physiologists, dietitians, and physical therapists, could be developed and become core locations for the promotion of HLM.
Mahé, Antoine; Faye, Ousmane; N'Diaye, Hawa Thiam; Konaré, Habibatou Diawara; Coulibaly, Ibrahima; Kéita, Somita; Traoré, Abdel Kader; Hay, Roderick J.
OBJECTIVE: To evaluate, in a developing country, the effect of a short training programme for general health care workers on the management of common skin diseases--a neglected component of primary health care in such regions. METHODS: We provided a one-day training programme on the management of the skin diseases to 400 health care workers who worked in primary health care centres in the Bamako area. We evaluated their knowledge and practice before and after training. FINDINGS: Before training, knowledge about skin diseases often was poor and practice inadequate. We found a marked improvement in both parameters after training. We analysed the registers of primary health care centres and found that the proportion of patients who presented with skin diseases who benefited from a clear diagnosis and appropriate treatment increased from 42% before the training to 81% after; this was associated with a 25% reduction in prescription costs. Improved levels of knowledge and practice persisted for up to 18 months after training. CONCLUSIONS: The training programme markedly improved the basic dermatological abilities of the health care workers targeted.