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1.  Setting priorities in primary health care - on whose conditions? A questionnaire study 
BMC Family Practice  2012;13:114.
In Sweden three key criteria are used for priority setting: severity of the health condition; patient benefit; and cost-effectiveness. They are derived from the ethical principles established by the Swedish parliament 1997 but have been used only to a limited extent in primary care. The aim of this study was to describe and analyse: 1) GPs', nurses', and patients' prioritising in routine primary care 2) The association between the three key priority setting criteria and the overall priority assigned by the GPs and nurses to individual patients.
Paired questionnaires were distributed to all patients and the GPs or nurses they had contact with during a 2-week period at four health centres in Sweden. The staff registered the health conditions or health problem, and the planned intervention. Then they estimated the severity of the health condition, the expected patient benefit, and the cost-effectiveness of the planned intervention. Both the staff and the patients reported their overall prioritisation of the patient. In total, 1851 paired questionnaires were collected.
Compared to the medical staff, the patients assigned relatively higher priority to acute/minor conditions than to preventive check-ups for chronic conditions. Severity of the health condition was the priority setting criterion that had the strongest association with the overall priority for the staff as a whole, but for the GPs it was cost-effectiveness.
The challenge for primary care providers is to balance the patients' demands with medical needs and cost-effectiveness. Transparent priority setting in primary care might contribute to a greater consensus between GPs and nurses on how to use the key priority setting criteria.
PMCID: PMC3528614  PMID: 23181453
2.  Primary care patients’ attitudes to priority setting in Sweden 
To analyse attitudes to priority setting among patients in Swedish primary healthcare.
A questionnaire was given to patients comprising statements on attitudes towards prioritizing, on the role of politicians and healthcare staff in prioritizing, and on patient satisfaction with the outcome of their contact with primary healthcare (PHC).
Four healthcare centres in Sweden, chosen through purposive sampling.
All the patients in contact with the health centres during a two-week period in 2004 (2517 questionnaires, 72% returned).
Main outcomes
Patient attitudes to priority setting and satisfaction with the outcome of their contact.
More than 75% of the patients agreed with statements like “Public health services should always provide the best possible care, irrespective of cost”. Almost three-quarters of the patients wanted healthcare staff rather than politicians to make decisions on priority setting. Younger patients and males were more positive towards priority setting and they also had a more positive view of the role of politicians. Less than 10% of the patients experienced some kind of economic rationing but the majority of these patients were satisfied with their contact with primary care.
Primary care patient opinions concerning priority setting are a challenge for both politicians and GPs. The fact that males and younger patients are less negative to prioritizing may pave the way for a future dialogue between politicians and the general public.
PMCID: PMC3410460  PMID: 19466679
Health priorities; family practice; patient participation; patient satisfaction; primary healthcare; rationing
3.  Development of guidelines for recently arrived immigrants and refugees to Canada: Delphi consensus on selecting preventable and treatable conditions 
Setting priorities is critical to ensure guidelines are relevant and acceptable to users, and that time, resources and expertise are used cost-effectively in their development. Stakeholder engagement and the use of an explicit procedure for developing recommendations are critical components in this process.
We used a modified Delphi consensus process to select 20 high-priority conditions for guideline development. Canadian primary care practitioners who care for immigrants and refugees used criteria that emphasize inequities in health to identify clinical care gaps.
Nine infectious diseases were selected, as well as four mental health conditions, three maternal and child health issues, caries and periodontal disease, iron-deficiency anemia, diabetes and vision screening.
Immigrant and refugee medicine covers the full spectrum of primary care, and although infectious disease continues to be an important area of concern, we are now seeing mental health and chronic diseases as key considerations for recently arriving immigrants and refugees.
PMCID: PMC3168668  PMID: 20547714
4.  Research priority setting for health policy and health systems strengthening in Nigeria: the policymakers and stakeholders perspective and involvement 
Nigeria is one of the low and middle income countries (LMICs) facing severe resource constraint, making it impossible for adequate resources to be allocated to the health sector. Priority setting becomes imperative because it guides investments in health care, health research and respects resource constraints. The objective of this study was to enhance the knowledge and understanding of policymakers on research priority setting and to conduct a research priority setting exercise.
A one-day evidence-to-policy research priority setting meeting was held. The meeting participants included senior and middle level policymakers and key decision makers/stakeholders in the health sector in Ebonyi State southeastern Nigeria. The priorities setting meeting involved a training session on priority setting process and conduction of priority setting exercise using the essential national health research (ENHR) approach. The focus was on the health systems building blocks (health workforce; health finance; leadership/governance; medical products/technology; service delivery; and health information/evidence).
Of the total of 92 policymakers invited 90(97.8%) attended the meeting. It was the consensus of the policymakers that research should focus on the challenges of optimal access to health products and technology; effective health service delivery and disease control under a national emergency situation; the shortfalls in the supply of professional personnel; and the issues of governance in the health sector management.
Research priority setting exercise involving policymakers is an example of demand driven strategy in the health policymaking process capable of reversing inequities and strengthening the health systems in LMICs.
PMCID: PMC3926765  PMID: 24570781
Research; priority setting; health policy; health system strengthening; policymakers; Africa
5.  Teamwork in primary care: perspectives of general practitioners and community nurses in Lithuania 
BMC Family Practice  2013;14:118.
A team approach in primary care has proven benefits in achieving better outcomes, reducing health care costs, satisfying patient needs, ensuring continuity of care, increasing job satisfaction among health providers and using human health care resources more efficiently. However, some research indicates constraints in collaboration within primary health care (PHC) teams in Lithuania. The aim of this study was to gain a better understanding of the phenomenon of teamwork in Lithuania by exploring the experiences of teamwork by general practitioners (GPs) and community nurses (CNs) involved in PHC.
Six focus groups were formed with 29 GPs and 27 CNs from the Kaunas Region of Lithuania. Discussions were recorded and transcribed verbatim. A thematic analysis of these data was then performed.
The analysis of focus group data identified six thematic categories related to teamwork in PHC: the structure of a PHC team, synergy among PHC team members, descriptions of roles and responsibilities of team members, competencies of PHC team members, communications between PHC team members and the organisational background for teamwork. These findings provide the basis for a discussion of a thematic model of teamwork that embraces formal, individual and organisational factors.
The need for effective teamwork in PHC is an issue receiving broad consensus; however, the process of teambuilding is often taken for granted in the PHC sector in Lithuania. This study suggests that both formal and individual behavioural factors should be targeted when aiming to strengthen PHC teams. Furthermore, this study underscores the need to provide explicit formal descriptions of the roles and responsibilities of PHC team members in Lithuania, which would include establishing clear professional boundaries. The training of team members is an essential component of the teambuilding process, but not sufficient by itself.
PMCID: PMC3751467  PMID: 23945286
Teamwork; General practitioners; Community nurses; Primary health care; Lithuania
6.  Key factors influencing adoption of an innovation in primary health care: a qualitative study based on implementation theory 
BMC Family Practice  2010;11:60.
Bridging the knowledge-to-practice gap in health care is an important issue that has gained interest in recent years. Implementing new methods, guidelines or tools into routine care, however, is a slow and unpredictable process, and the factors that play a role in the change process are not yet fully understood. There is a number of theories concerned with factors predicting successful implementation in various settings, however, this issue is insufficiently studied in primary health care (PHC). The objective of this article was to apply implementation theory to identify key factors influencing the adoption of an innovation being introduced in PHC in Sweden.
A qualitative study was carried out with staff at six PHC units in Sweden where a computer-based test for lifestyle intervention had been implemented. Two different implementation strategies, implicit or explicit, were used. Sixteen focus group interviews and two individual interviews were performed. In the analysis a theoretical framework based on studies of implementation in health service organizations, was applied to identify key factors influencing adoption.
The theoretical framework proved to be relevant for studies in PHC. Adoption was positively influenced by positive expectations at the unit, perceptions of the innovation being compatible with existing routines and perceived advantages. An explicit implementation strategy and positive opinions on change and innovation were also associated with adoption. Organizational changes and staff shortages coinciding with implementation seemed to be obstacles for the adoption process.
When implementation theory obtained from studies in other areas was applied in PHC it proved to be relevant for this particular setting. Based on our results, factors to be taken into account in the planning of the implementation of a new tool in PHC should include assessment of staff expectations, assessment of the perceived need for the innovation to be implemented, and of its potential compatibility with existing routines. Regarding context, we suggest that implementation concurrent with other major organizational changes should be avoided. The choice of implementation strategy should be given thorough consideration.
PMCID: PMC2933616  PMID: 20731817
7.  Assessment of the Knowledge of Primary Health Care Staff about Primary Health Care 
The orientation about Primary Health Care among staff working in the PHC centers was assessed. Staff members numbering 909 were studied. The main criteria for judging orientation were a working knowledge of the definition and elements of PHC in addition to knowledge of the meaning of the word Alma Ata. Differences of this knowledge depending on sex, age, spoken language, type of job, postgraduate experience, previous experience in PHC and previous training in PHC were assessed. The main findings of the study were that the correct definition of PHC was known by only 51.4%, functions of PHC by 62.6%, and what Alma Ata, means in terms of PHC was known by 76.2% of the staff. This knowledge was significantly better in females than males, non-Arabic speaking staff than those who spoke Arabic, General practitioners and nurses than other staff; it was better in those staff who had long postgraduate experience, previous experience or previous training in PHC.
In conclusion, the study reveals the current status of awareness of PHC staff of the implications of simple concepts of PHC and points to the importance of the orientation of staff towards these concepts in order to help them practice PHC effectively.
PMCID: PMC3437150  PMID: 23012208
Primary health care; Alma Ata; General practitioners; Nurses
8.  Identifying research priorities for health care priority setting: a collaborative effort between managers and researchers 
To date there has been relatively little published about how research priorities are set, and even less about methods by which decision-makers can be engaged in defining a relevant and appropriate research agenda. We report on a recent effort in British Columbia to have researchers and decision-makers jointly establish an agenda for future research into questions of resource allocation.
The researchers enlisted decision-maker partners from each of British Columbia's six health authorities. Three forums were held, at which researchers and decision-makers from various levels in the health authorities considered possible research areas related to three key focus areas: (1) generation and use of decision criteria and measurement of 'benefit' against such criteria; (2) identification of so-called 'disinvestment' opportunities; and (3) evaluation of the effectiveness of priority setting procedures. Detailed notes were taken from each forum and synthesized into a set of qualitative themes.
Forum participants suggested that future research into healthcare priority setting would benefit from studies that were longitudinal, comparative, and/or interdisciplinary. As well, participants identified two broad theme areas in which specific research projects were deemed desirable. First, future research might usefully consider how formal priority setting and resource allocation projects are situated within a larger organizational and political context. Second, additional research efforts should be devoted to better understanding and improving the actual implementation of priority setting frameworks, particularly with respect to issues of change management and the resolution of impediments to action on recommendations for resource allocation.
We were able to validate the importance of initial areas posed to the group and observed emergence of additional concerns and directions of critical importance to these decision-makers at this time. It is likely that the results are broadly applicable to other healthcare contexts. The implementation of this research agenda in British Columbia will depend upon the ability of the researchers and decision-makers to develop particular projects that fit within the constraints of existing funding opportunities. The process of engagement itself had benefits in terms of connecting decision-makers with their peers and sparking increased interest in the use and refinement of priority setting frameworks.
PMCID: PMC2755472  PMID: 19754969
9.  Staff perceptions of addressing lifestyle in primary health care: a qualitative evaluation 2 years after the introduction of a lifestyle intervention tool 
BMC Family Practice  2012;13:99.
Preventive services and health promotion in terms of lifestyle counselling provided through primary health care (PHC) has the potential to reduce morbidity and mortality in the population. Health professionals in general are positive about and willing to develop a health-promoting and/or preventive role. A number of obstacles hindering PHC staff from addressing lifestyle issues have been identified, and one facilitator is the use of modern technology. When a computer-based tool for lifestyle intervention (CLT) was introduced at a number of PHC units in Sweden, this provided an opportunity to study staff perspectives on the subject. The aim of this study was to explore PHC staff’s perceptions of handling lifestyle issues, including the consultation situation as well as the perceived usefulness of the CLT.
A qualitative study was conducted after the CLT had been in operation for 2 years. Six focus group interviews, one at each participating unit, including a total of 30 staff members with different professions participated. The interviews were designed to capture perceptions of addressing lifestyle issues, and of using the CLT. Interview data were analysed using manifest content analysis.
Two main themes emerged from the interviews: a challenging task and confidence in handling lifestyle issues. The first theme covered the categories responsibilities and emotions, and the second theme covered the categories first contact, existing tools, and role of the CLT. Staff at the units showed commitment to health promotion/prevention, and saw that patients, caregivers, managers and politicians all have responsibilities regarding the issue. They expressed confidence in handling lifestyle-related conditions, but to a lesser extent had routines for general screening of lifestyle habits, and found addressing alcohol the most problematic issue. The CLT, intended to facilitate screening, was viewed as a complement, but was not considered an important tool for health promotion/prevention.
Additional resources, for example in terms of manpower, may help to build the structures necessary for the health promotion/prevention task. Committed leaders could enhance the engagement among staff. Cooperation in multi-professional teams seems to be important, and methods or tools perceived by staff as compatible have a potential to be successfully implemented. Economic incentives rewarding quantity rather than quality appear to be frustrating to PHC staff.
PMCID: PMC3515336  PMID: 23052150
Staff perception; Lifestyle counselling; Primary health care; Computerized tool
10.  The missing link – the role of primary care in global health 
Global Health Action  2014;7:10.3402/gha.v7.23693.
This chapter provides an overview of the role of primary care in the context of global health. Universal health coverage is a key priority for WHO and its member states, and provision of accessible and safe primary care is recognised as essential to meet this important international policy goal. Nevertheless, more than three decades after Alma Ata, the provision of primary health care remains inadequate, indicating that primary care has not received the priority it deserves, in many parts of the world. This is despite the proven health benefits that result from access to comprehensive primary health care. We highlight some examples of good practice and discuss the relevance of primary care in the context of health equity and cost-effectiveness. Challenges that influence the success of primary care include the availability of a qualified workforce, financing and system design and quality assurance and patient safety.
PMCID: PMC3926992  PMID: 24560266
primary care; global health; universal health coverage; health equity
11.  Multi-criteria decision analysis for setting priorities on HIV/AIDS interventions in Thailand 
A wide range of preventive, treatment, and care programs for HIV/AIDS are currently available and some of them have been implemented in Thailand. Policy makers are now facing challenges on how the scarce resources for HIV/AIDS control can be spent more wisely. Although effectiveness and cost-effectiveness information is useful for guiding policy decisions, empirical evidence indicates the importance of other criteria, such as equity and the characteristics of the target population, also play important roles in priority setting. This study aims to experiment with the use of multi-criteria decision analysis (MCDA) to prioritise interventions in HIV/AIDS control in Thailand.
We used MCDA to rank 40 HIV/AIDS interventions on the basis of the priority setting criteria put forward by three groups of stakeholders including policy makers, people living with HIV/AIDs (PLWHA), and village health volunteers (VHVs). MCDA incorporated an explicit component of deliberation to let stakeholders reflect on the rank ordering, and adapt where necessary.
Upon deliberation, policy makers expressed a preference for programs that target high risk groups such as men who have sex with men, injecting drug users, and female sex workers. The VHVs preferred interventions that target the youth or the general population, and gave lower priority to programs that target high risk groups. PLWHA gave all interventions the same priority. The rank order correlation between the priorities as expressed before and after deliberation was 37% among the policy makers and 46% among the VHVs.
This study documented the feasibility of MCDA to prioritize HIV/AIDS interventions in Thailand, and has shown the usefulness of a deliberative process as an integrated component of MCDA. MCDA holds potential to contribute to a more transparent and accountable priority setting process, and further application of this approach in the prioritisation of health interventions is warranted.
PMCID: PMC3310796  PMID: 22339981
Multi-criteria decision analysis; Priority setting; HIV/AIDS interventions; Discrete choice experiment
12.  Setting priorities in health care organizations: criteria, processes, and parameters of success 
Hospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly.
We facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making.
Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly.
PMCID: PMC518972  PMID: 15355544
13.  Doctors' perceptions of palliative care for heart failure: focus group study 
BMJ : British Medical Journal  2002;325(7364):581-585.
To identify doctors' perceptions of the need for palliative care for heart failure and barriers to change.
Qualitative study with focus groups.
North west England.
General practitioners and consultants in cardiology, geriatrics, palliative care, and general medicine.
Doctors supported the development of palliative care for patients with heart failure with the general practitioner as a central figure. They were reluctant to endorse expansion of specialist palliative care services. Barriers to developing approaches to palliative care in heart failure related to three main areas: the organisation of health care, the unpredictable course of heart failure, and the doctors' understanding of roles. The health system was thought to work against provision of holistic care, exacerbated by issues of professional rivalry and control. The priorities identified for the future were developing the role of the nurse, better community support for primary care, and enhanced communication between all the health professionals involved in the care of patients with heart failure.
Greater consideration should be given to the care of patients dying with heart failure, clarifying the roles of doctors and nurses in different specialties, and reshaping the services provided for them. Many of the organisational and professional issues are not peculiar to patients dying with heart failure, and addressing such concerns as the lack of coordination and continuity in medical care would benefit all patients.
What is already known on this topicPatients with heart failure have unmet needs for health care at the end of lifeSpecialist palliative care services see few patients with heart failureThe national service framework for coronary heart disease endorses the provision of palliative care for heart failureLittle evidence exists on how this care should be provided, and doctors' views are not knownWhat this study addsBarriers to adopting a palliative care approach in heart failure care relate to the current organisation of health services, the difficulties of prognostication, and doctors' understanding of roles and responsibilitiesDoctors believe that the general practitioner should be the central figure in palliative care for heart failure, supported by specialistsDoctors' future priorities are developing the role of nurses, increasing essential community services, such as district nursing, and improving communication with colleagues
PMCID: PMC124557  PMID: 12228136
14.  Nurse delivered lifestyle interventions in primary health care to treat chronic disease risk factors associated with obesity: a systematic review 
Obesity Reviews  2012;13(12):1148-1171.
Nurses in primary health care (PHC) provide an increasing proportion of chronic disease management and preventive lifestyle advice. The databases MEDLINE, CINAHL, EMBASE and PsychINFO were searched and the articles were systematically reviewed for articles describing controlled adult lifestyle intervention studies delivered by a PHC nurse, in a PHC setting. Thirty-one articles describing 28 studies were analysed by comparison group which revealed: (i) no difference of effect when the same intervention was delivered by a PHC nurse compared to other health professionals in PHC (n = 2); (ii) the provision of counselling delivered by a PHC nurse was more effective than health screening (n = 10); (iii) counselling based on behaviour change theory was more effective than the same dose of non-behavioural counselling when at least three counselling sessions were delivered (n = 3). The evidence supports the effectiveness of lifestyle interventions delivered by nurses in PHC to affect positive changes on outcomes associated with the prevention of chronic disease including: weight, blood pressure, cholesterol, dietary and physical activity behaviours, patient satisfaction, readiness for change and quality of life. The strength of recommendations is limited by the small number of studies within each comparison group and the high risk of bias of the majority of studies.
PMCID: PMC3533768  PMID: 22973970
Chronic disease prevention; lifestyle intervention; nursing; primary health care
15.  Is cost-effectiveness analysis preferred to severity of disease as the main guiding principle in priority setting in resource poor settings? The case of Uganda 
Several studies carried out to establish the relative preference of cost-effectiveness of interventions and severity of disease as criteria for priority setting in health have shown a strong preference for severity of disease. These preferences may differ in contexts of resource scarcity, as in developing countries, yet information is limited on such preferences in this context.
This study was carried out to identify the key players in priority setting in health and explore their relative preference regarding cost-effectiveness of interventions and severity of disease as criteria for setting priorities in Uganda.
610 self-administered questionnaires were sent to respondents at national, district, health sub-district and facility levels. Respondents included mainly health workers. We used three different simulations, assuming same patient characteristics and same treatment outcome but with varying either severity of disease or cost-effectiveness of treatment, to explore respondents' preferences regarding cost-effectiveness and severity.
Actual main actors were identified to be health workers, development partners or donors and politicians. This was different from what respondents perceived as ideal. Above 90% of the respondents recognised the importance of both severity of disease and cost-effectiveness of intervention. In the three scenarios where they were made to choose between the two, a majority of the survey respondents assigned highest weight to treating the most severely ill patient with a less cost-effective intervention compared to the one with a more cost-effective intervention for a less severely ill patient. However, international development partners in in-depth interviews preferred the consideration of cost-effectiveness of intervention.
In a survey among health workers and other actors in priority setting in Uganda, we found that donors are considered to have more say than the survey respondents found ideal. Survey respondents considered both severity of disease and cost-effectiveness important criteria for setting priorities, with severity of disease as the leading principle. This pattern of preferences is similar to findings in context with relatively more resources. In-depth interviews with international development partners, showed that this group put relatively more emphasis on cost-effectiveness of interventions compared to severity of disease. These discrepancies in attitudes between national health workers and representatives from the donors require more investigation. The different attitudes should be openly debated to ensure legitimate decisions.
PMCID: PMC324572  PMID: 14711374
Cost-effectiveness; health care rationing; severity of disease; priority setting; and developing countries
16.  Priority setting in a Canadian surgical department: a case study using program budgeting and marginal analysis 
Canadian Journal of Surgery  2003;46(1):23-29.
A key mandate of Canadian regional health authorities is to set priorities and allocate resources within a limited funding envelope. The objective in this study was to determine how resources within a surgical program in a Canadian rural hospital might be reallocated to better meet the needs of the local community.
Early in 2001, at the Canmore General Hospital, Canmore, Alta., an expert-panel working group, consisting of a community health service leader, operating-room nurse clinician, acute care head nurse and a general surgeon, assisted by a research assistant and 2 health economists carried out a program budgeting and marginal analysis project to assess multiple data inputs into the decision-making process and to develop recommendations for service expansion and resource release. They considered the cost and benefits of altering the mix of resources used, based on Headwaters Health Authority activity and financial data, and local expert opinion.
The primary recommendation was to implement an additional surgery day per week (38 days of major surgery and 12 days of minor surgery over a 50-week year). However, the total dollars to fund such an expansion could not be released from within the Canmore budget, and additional dollars were not forthcoming from the health region. A secondary objective of implementing an additional minor surgery day every 3 weeks was pursued and the required resources were obtained.
Due to resource constraints in health care, efforts by both clinicians and administrators should be made to better spend available resources. The marginal analysis process used in this study served as a useful framework for priority setting, which is generalizable to other surgical and nonsurgical programs in Canada.
PMCID: PMC3211667  PMID: 12585790
17.  Health care priority setting in Norway a multicriteria decision analysis 
Priority setting in population health is increasingly based on explicitly formulated values. The Patients Rights Act of the Norwegian tax-based health service guaranties all citizens health care in case of a severe illness, a proven health benefit, and proportionality between need and treatment. This study compares the values of the country's health policy makers with these three official principles.
In total 34 policy makers participated in a discrete choice experiment, weighting the relative value of six policy criteria. We used multi-variate logistic regression with selection as dependent valuable to derive odds ratios for each criterion. Next, we constructed a composite league table - based on the sum score for the probability of selection - to rank potential interventions in five major disease areas.
The group considered cost effectiveness, large individual benefits and severity of disease as the most important criteria in decision making. Priority interventions are those related to cardiovascular diseases and respiratory diseases. Less attractive interventions rank those related to mental health.
Norwegian policy makers' values are in agreement with principles formulated in national health laws. Multi-criteria decision approaches may provide a tool to support explicit allocation decisions.
PMCID: PMC3312861  PMID: 22335815
18.  Physical activity referrals in Swedish primary health care – prescriber and patient characteristics, reasons for prescriptions, and prescribed activities 
Over the past decade, practitioners in primary health care (PHC) settings in many countries have issued written prescriptions to patients to promote increased physical activity or exercise. The aim of this study is to describe and analyse a comprehensive physical activity referral (PAR) scheme implemented in a routine PHC setting in Östergötland County. The study examines characteristics of the PARs recipients and referral practitioners, identifies reasons why practitioners opted to use PARs with their clients, and discusses prescribed activities and prescriptions in relation to PHC registries.
Prospective prescription data were obtained for 90% of the primary health care centres in Östergötland County, Sweden, in 2004 and 2005. The study population consisted of patients who were issued PARs after they were deemed likely to benefit from increased physical activity, as assessed by PHC staff.
During the two-year period, a total of 6,300 patients received PARs. Two-thirds of the patients were female and half of the patients were 45–64 years. Half of the patients (50.8%) who received PARs were recommended a home-based activity, such as walking. One third (33%) of the patients issued PARs were totally inactive, reporting no days of physical activity that lasted for 30 minutes, and 29% stated that they reached this level 1–2 days per week.
The number of PARs prescribed per year in relation to the number of unique individuals that visited primary health care during one year was 1.4% in 2004 and 1.2% in 2005. Two-thirds of the combined prescriptions were issued by physicians (38%) and nurses (31%). Physiotherapists and behavioural scientists issued the highest relative number of prescriptions. The most common reasons for issuing PARs were musculoskeletal disorders (39.1%) and overweight (35.4%), followed by high blood pressure (23.3%) and diabetes (23.2%).
Östergötland County's PAR scheme reached a relatively high proportion of physically inactive people visiting local PHC centres for other health reasons. PAR-related statistics, including PAR-rates by individual PHC centres and PAR- rates per health professional category, show differences in prescribing activities, both by patient categories, and by prescribing professionals.
PMCID: PMC2567971  PMID: 18828898
19.  The acceptability of waiting times for elective general surgery and the appropriateness of prioritising patients 
Problematic waiting lists in public health care threaten the equity and timeliness of care provision in several countries. This study assesses different stakeholders' views on the acceptability of waiting lists in health care, their preferences for priority care of patients, and their judgements on acceptable waiting times for surgical patients.
A questionnaire survey was conducted among 257 former patients (82 with varicose veins, 86 with inguinal hernia, and 89 with gallstones), 101 surgeons, 95 occupational physicians, and 65 GPs. Judgements on acceptable waiting times were assessed using vignettes of patients with varicose veins, inguinal hernia, and gallstones.
Participants endorsed the prioritisation of patients based on clinical need, but not on ability to benefit. The groups had significantly different opinions (p < 0.05) on the use of non-clinical priority criteria and on the need for uniformity in the prioritisation process.
Acceptable waiting times ranged between 2 and 25 weeks depending on the type of disorder (p < 0.001) and the severity of physical and psychosocial problems of patients (p < 0.001). Judgements were similar between the survey groups (p = 0.3) but responses varied considerably within each group depending on the individual's attitude towards waiting lists in health care (p < 0.001).
The explicit prioritisation of patients seems an accepted means for reducing the overall burden from waiting lists. The disagreement about appropriate prioritisation criteria and the need for uniformity, however, raises concern about equity when implementing prioritisation in daily practice.
Single factor waiting time thresholds seem insufficient for securing timely care provision in the presence of long waiting lists as they do not account for the different consequences of waiting between patients.
PMCID: PMC1847814  PMID: 17328816
20.  What do District Health Planners in Tanzania think about improving priority setting using 'Accountability for Reasonableness'? 
Priority setting in every health system is complex and difficult. In less wealthy countries the dominant approach to priority setting has been Burden of Disease (BOD) and cost-effectiveness analysis (CEA), which is helpful, but insufficient because it focuses on a narrow range of values – need and efficiency – and not the full range of relevant values, including legitimacy and fairness. 'Accountability for reasonableness' is a conceptual framework for legitimate and fair priority setting and is empirically based and ethically justified. It connects priority setting to broader, more fundamental, democratic deliberative processes that have an impact on social justice and equity. Can 'accountability for reasonableness' be helpful for improving priority setting in less wealthy countries?
In 2005, Tanzanian scholars from the Primary Health Care Institute (PHCI) conducted 6 capacity building workshops with senior health staff, district planners and managers, and representatives of the Tanzanian Ministry of Health to discussion improving priority setting in Tanzania using 'accountability for reasonableness'. The purpose of this paper is to describe this initiative and the participants' views about the approach.
The approach to improving priority setting using 'accountability for reasonableness' was viewed by district decision makers with enthusiastic favour because it was the first framework that directly addressed their priority setting concerns. High level Ministry of Health participants were also very supportive of the approach.
Both Tanzanian district and governmental health planners viewed the 'accountability for reasonableness' approach with enthusiastic favour because it was the first framework that directly addressed their concerns.
PMCID: PMC2151948  PMID: 17997824
21.  Effect of educational outreach to nurses on tuberculosis case detection and primary care of respiratory illness: pragmatic cluster randomised controlled trial 
BMJ : British Medical Journal  2005;331(7519):750-754.
Objectives To develop and implement an educational outreach programme for the integrated case management of priority respiratory diseases (practical approach to lung health in South Africa; PALSA) and to evaluate its effects on respiratory care and detection of tuberculosis among adults attending primary care clinics.
Design Pragmatic cluster randomised controlled trial, with clinics as the unit of randomisation.
Setting 40 primary care clinics, staffed by nurse practitioners, in the Free State province, South Africa.
Participants 1999 patients aged 15 or over with cough or difficult breathing (1000 in intervention clinics, 999 in control clinics).
Intervention Between two and six educational outreach sessions delivered to nurse practitioners by usual trainers from the health department. The emphasis was on key messages drawn from the customised clinical practice guideline for the outreach programme, with illustrative support materials.
Main outcome measures Sputum screening for tuberculosis, tuberculosis case detection, inhaled corticosteroid prescriptions for obstructive lung disease, and antibiotic prescriptions for respiratory tract infections.
Results All clinics and almost all patients (92.8%, 1856/1999) completed the trial. Although sputum testing for tuberculosis was similar between the groups (22.6% in outreach group v 19.3% in control group; odds ratio 1.22, 95% confidence interval 0.83 to 1.80), the case detection of tuberculosis was higher in the outreach group (6.4% v 3.8%; 1.72, 1.04 to 2.85). Prescriptions for inhaled corticosteroids were also higher (13.7% v 7.7%; 1.90, 1.14 to 3.18) but the number of antibiotic prescriptions was similar (39.7% v 39.4%; 1.01, 0.74 to 1.38).
Conclusions Combining educational outreach with integrated case management provides a promising model for improving quality of care and control of priority respiratory diseases, without extra staff, in resource poor settings.
Trial registration Current controlled trials ISRCTN13438073.
PMCID: PMC1239979  PMID: 16195293
22.  Setting priorities for research and development in the NHS: a case study on the interface between primary and secondary care. 
BMJ : British Medical Journal  1995;311(7012):1076-1080.
Since 1991 the NHS has attempted to identify and prioritise its needs for research and development in a systematic manner. This has not been done before and there is little evidence on which to draw. Multidisciplinary expert groups have identified priorities in different topics using explicit criteria and after widespread consultation within the NHS and research community to identify pressing problems and opportunities for research. This paper focuses on a review completed in 1993 to identify research and development priorities for the NHS in relation to the interface between primary and secondary care. The review covered several recent developments which require evaluation. The authors describe the process used to identify research and development priorities in this complex subject and examine the strengths and weaknesses of the approach. This case study should help to stimulate a wider debate on methods of identifying priorities, particularly those using participatory approaches, in research and non-research contexts.
PMCID: PMC2551374  PMID: 7580669
23.  Perceived barriers to integrated care in rheumatoid arthritis: views of recipients and providers of care in an inner-city setting 
A number of recent reports published in the UK have put the quality of care of adults with Rheumatoid Arthritis (RA) centre stage. These documents set high standards for health care professionals and commissioning bodies that need to be implemented into routine clinical practice. We therefore have obtained the views of recipients and providers of care in inner city settings as to what they perceive are the barriers to providing integrated care.
We conducted focus groups and face to face interviews between 2005-8 with 79 participants (patients, carers, specialist medical and nursing outpatient staff and general practitioners (GPs)) working in or attending three hospitals and three primary care trusts (PCT).
Three barriers were identified that stood in the way of seamless integrated care in RA from the perspective of patients, carers, specialists and GPs: (i) early referral (e.g. 'gate keeper's role of GPs); (ii) limitations of ongoing care for established RA (e.g. lack of consultation time in secondary care) and (iii) management of acute flares (e.g. pressure on overbooked clinics).
This timely study of the multi-perspective views of recipients and providers of care was conducted during the time of publications of many important reports in the United Kingdom (UK) that highlighted key components in the provision of high quality care for adults with RA. To achieve seamless care across primary and secondary care requires organisational changes, greater personal and professional collaboration and GP education about RA.
PMCID: PMC3031274  PMID: 21241497
24.  Recommended content of referral letters from general practitioners to specialised mental health care: a qualitative multi-perspective study 
In most Western countries, the referral letter forms the basis for establishing the priority of patients for specialised health care and for the coordination of care between the services. To be able to define the quality of referral letters, the potential impact of the quality on the organisation of care, and to improve the quality of the letters, we need a multidimensional definition of the ideal content. The study’s aim was to explore what information is seen as most important and should be included in referral letters from primary care to specialised mental health care to facilitate prioritisation and planning of treatment and follow-up of the patients.
Based on purposive sampling, four mixed discussion groups, which included general practitioners, mental health nurses from primary health care, psychiatrists and psychologists from specialised mental health care, managers and patient representatives, were formed; they were asked to identify the information they considered important in a mental health referral letter. In line with the Delphi technique, the importance of the themes was later individually rated by the participants. The study was conducted within The Western Norway Regional Health Authority.
The four groups identified 174 information themes. After excluding themes that were assessed as duplicates, replaceable or less important, 40 themes were suggested, organised in seven units. A set of check-off points of essential information is recommended as an introduction in the referral letter.
Compared with general guidelines and guidelines for somatic care, the results of this study suggest that the referral letter to specialised mental health care should have a larger emphasis on the overall treatment plan, on the specific role of specialised health care in the continuum of care, and on patient involvement. Further research should evaluate the validity of these findings for other patient groups in need of integrated care and investigate how the quality of referral letters affects patient-related and organisational outcomes.
Trial Registration
Trial Registration number: NCT01374035
PMCID: PMC3751904  PMID: 23958371
Referral and consultation; Mental health; Health services; General practice; Group interview
25.  Rapid appraisal of needs in reproductive health care in southern Sudan: qualitative study 
BMJ : British Medical Journal  1999;319(7212):743-748.
To identify the need for reproductive health care among a community affected by conflict, and to ascertain the priority given by the community to reproductive health issues.
Rapid appraisal. This comprised interviews with key informants, in-depth interviews, and group discussions. Secondary data were collated. Freelisting, ranking, and scenarios were used to obtain information.
Communities affected by conflict in southern Sudan.
Interviews and group discussions were chosen purposively. Twenty interviews with key informants were undertaken, in-depth interviews were held with 14 women, and 23 group discussions were held.
Main outcome measures
Need for reproductive health care. Perceived priority afforded to reproductive health issues in comparison with other health problems.
Reproductive health in general and sexually transmitted diseases in particular were important issues for these communities. Problems in reproductive health were ranked differently depending on the age and sex of the respondents. Perceptions about reproductive health issues in communities varied between service providers, and community leaders. Settled and displaced communities had different priorities and differing experiences of reproductive health problems and their treatment.
Rapid appraisal could be used as the first step to involving communities in assessing needs and planning service provision.
Key messagesCommunity members are not routinely involved in assessing their needs or identifying priorities for humanitarian aidReproductive health needs were important to this population affected by conflictCommunity leaders and health service providers will not necessarily hold the same view of need as community membersPeople of different age, sex, and circumstance are likely to perceive community needs differentlyRapid appraisal may be a useful tool to involve communities living in these contexts to identify their needs and priorities
PMCID: PMC28227  PMID: 10488000

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