Although most people with Type 2 diabetes receive their diabetes care in primary care, only a limited amount is known about the quality of diabetes care in this setting. We investigated the provision and receipt of diabetes care delivered in UK primary care.
Postal surveys with all healthcare professionals and a random sample of 100 patients with Type 2 diabetes from 99 UK primary care practices.
326/361 (90.3%) doctors, 163/186 (87.6%) nurses and 3591 patients (41.8%) returned a questionnaire. Clinicians reported giving advice about lifestyle behaviours (e.g. 88% would routinely advise about calorie restriction; 99.6% about increasing exercise) more often than patients reported having received it (43% and 42%) and correlations between clinician and patient report were low. Patients’ reported levels of confidence about managing their diabetes were moderately high; a median (range) of 21% (3% to 39%) of patients reporting being not confident about various areas of diabetes self-management.
Primary care practices have organisational structures in place and are, as judged by routine quality indicators, delivering high quality care. There remain evidence-practice gaps in the care provided and in the self confidence that patients have for key aspects of self management and further research is needed to address these issues. Future research should use robust designs and appropriately designed studies to investigate how best to improve this situation.
Nurses are the primary healthcare providers in correctional facilities. A solid knowledge and expertise that includes the use of research evidence in clinical decision making is needed to optimize nursing practice and promote positive health outcomes within these settings. The institutional emphasis on custodial care within a heavily secured, regulated, and punitive environment presents unique contextual challenges for nursing practice. Subsequently, correctional nurses are not always able to obtain training or ongoing education that is required for broad scopes of practice. The purpose of the proposed study is to develop an educational intervention for correctional nurses to support the provision of evidence-informed care.
A two-phase mixed methods research design will be used. The setting will be three provincial correctional facilities. Phase one will focus on identifying nurses’ scope of practice and practice needs, describing work environment characteristics that support evidence-informed practice and developing the intervention. Semi-structured interviews will be completed with nurses and nurse managers. To facilitate priorities for the intervention, a Delphi process will be used to rank the learning needs identified by participants. Based on findings, an online intervention will be developed. Phase two will involve evaluating the acceptability and feasibility of the intervention to inform a future experimental design.
The context of provincial correctional facilities presents unique challenges for nurses’ provision of care. This study will generate information to address practice and learning needs specific to correctional nurses. Interventions tailored to barriers and supports within specific contexts are important to enable nurses to provide evidence-informed care.
Nurses; Nursing; Corrections; Prisons; Evidence-informed care; Education intervention; Learning needs; Work environments
To determine whether there are any age-related disparities in the frequency of provision of counseling and education for diabetes care in a large HMO in Central Texas.
EMR search from 13 primary care clinics on patients aged ≥18 years (n=1300) who had been diagnosed with type 2 diabetes.
There were no significant age differences in the frequency of provision of counseling about HBGM, diet, smoking or diabetes education. However, there were significant age differences in the provision of exercise counseling. Patients aged ≥75 were significantly less likely to have been provided exercise counseling than those aged <65 (adjusted OR=0.60; 95% CI=0.37–0.98). The mean HbA1c for patients aged ≥75 and 65–74 were significantly lower than that of patients aged <65 (8.9 vs. 9.0 vs. 9.7; P<.001).
While age-related variations in self-management protocols were not found, the provision of formal diabetes education was low (29.4%). The persistence of key risk factors in later life (e.g., obesity) underscores the need for better self-management protocols for older adults.
Additional efforts on strategies to increase counseling about lifestyle habits and diabetes self-management care by appropriate health care providers is needed. Diabetes counseling should be individually tailored in older population.
Age-related disparities; health disparities; type 2 diabetes
Since the launching of Global Initiative, VISION 2020 “the Right to Sight” many innovative, practical and unique comprehensive eye care services provision models have evolved targeting the underserved populations in different parts of the World. At places the rapid assessment of the burden of eye diseases in confined areas or utilizing the key informants for identification of eye diseases in the communities are promoted for better planning and evidence based advocacy for getting / allocation of resources for eye care. Similarly for detection and management of diabetes related blindness, retinopathy of prematurity and avoidable blindness at primary level, the major obstacles are confronted in reaching to them in a cost effective manner and then management of the identified patients accordingly. In this regard, the concept of tele-ophthalmology model sounds to be the best solution. Whereas other models on comprehensive eye care services provision have been emphasizing on surgical output through innovative scales of economy that generate income for the program and ensure its sustainability, while guaranteeing treatment of the poorest of the poor.
Diabetes-related blindness; diabetic retinopathy; key informant; rapid assessment of avoidable blindness; retinopathy of prematurity; tele-ophthalmology
The delivery of best practice care can markedly improve clinical outcomes in patients with chronic disease. While the provision of a skilled, multidisciplinary team is pivotal to the delivery of best practice care, the occupational or skill mix required to deliver this care is unclear; it is also uncertain whether such a team would have the capacity to adequately address the complex needs of the clinic population. This is the role of needs-based health workforce planning. The objective of this article is to describe the development of an evidence-informed, needs-based health workforce model to support the delivery of best-practice interdisciplinary chronic disease management in the primary and community care setting using diabetes as a case exemplar.
Development of the workforce model was informed by a strategic review of the literature, critical appraisal of clinical practice guidelines, and a consensus elicitation technique using expert multidisciplinary clinical panels. Twenty-four distinct patient attributes that require unique clinical competencies for the management of diabetes in the primary care setting were identified. Patient attributes were grouped into four major themes and developed into a conceptual model: the Workforce Evidence-Based (WEB) planning model. The four levels of the WEB model are (1) promotion, prevention, and screening of the general or high-risk population; (2) type or stage of disease; (3) complications; and (4) threats to self-care capacity. Given the number of potential combinations of attributes, the model can account for literally millions of individual patient types, each with a distinct clinical team need, which can be used to estimate the total health workforce requirement.
The WEB model was developed in a way that is not only reflective of the diversity in the community and clinic populations but also parsimonious and clear to present and operationalize. A key feature of the model is the classification of subpopulations, which gives attention to the particular care needs of disadvantaged groups by incorporating threats to self-care capacity. The model can be used for clinical, health services, and health workforce planning.
People with non-diabetic hyperglycaemia might be at risk of lacking adequate control for cardiovascular risk factors. Our aim was to determine the extent of health care utilization and provision in primary care and to evaluate the risk of cardiovascular disease in persons with an elevated risk score in a stepwise diabetes screening programme.
A total of 56,978 non-diabetic patients, aged 50–70 years, from 79 practices in the Netherlands were invited to participate in a screening programme starting with a questionnaire. Those with an elevated score, underwent further glucose testing. Screened participants with type 2 diabetes (n = 64), impaired glucose tolerance (IGT) (n = 62), impaired fasting glucose (IFG) (n = 86), and normal glucose tolerance (NGT) (n = 142) were compared after three years regarding use of medication, care provider encounters and occurrence of CVD.
In all glucose regulation categories cardiovascular medication was prescribed more frequently during follow-up with the strongest increase in diabetic patients. Number of practice visits was higher in diabetic patients compared to those in the other categories. Glucose, lipids, and blood pressure were measured most frequently in diabetic patients. Numbers of cardiovascular events in participants with NGT, IFG, IGT and diabetes were 16.7, 32.6, 17.3 and 15.7 per 1,000 person-years (non significant), respectively.
After three years of follow-up, screened non-diabetic participants with an elevated risk score had cardiovascular event rates comparable with diabetic patients. Screened non-diabetic persons are at risk of lacking optimal control for cardiovascular risk factors while screen-detected diabetic patients were controlled adequately.
India has a proud tradition of blindness prevention, being the first country in the world to implement a blindness control programme which focused on a model to address blinding eye disease. However, with 133 million people blind or vision impaired due to the lack of an eye examination and provision of an appropriate pair of spectacles, it is imperative to establish a cadre of eye care professionals to work in conjunction with ophthalmologists to deliver comprehensive eye care. The integration of highly educated four year trained optometrists into primary health services is a practical means of correcting refractive error and detecting ocular disease, enabling co-managed care between ophthalmologists and optometrists. At present, the training of optometrists varies from two year trained ophthalmic assistants/optometrists or refractionists to four year degree trained optometrists. The profession of optometry in India is not regulated, integrated into the health care system or recognised by the majority of people in India as provider of comprehensive eye care services. In the last two years, the profession of optometry in India is beginning to take the necessary steps to gain recognition and regulation to become an independent primary health care profession. The formation of the Indian Optometry Federation as the single peak body of optometry in India and the soon to be established Optometry Council of India are key organisations working towards the development and regulation of optometry.
Comprehensive eye care; optometrist; optometry regulation; eye health; India
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.
primary care; global health; universal health coverage; health equity
The ease with which patients can make primary care appointments in the UK has been subject to a pay for performance scheme since 2004. A separate scheme, extended hours — the provision of extra appointments outside normal office hours —was introduced in 2008.
To examine how the provision of additional morning, evening, and weekend appointments influences patient satisfaction with opening hours.
Design and setting
An observational study in primary care.
The study collated information on extended hours for all practices in 13 English primary care trusts (n = 639). After examining the descriptive statistics the study ran a series of clustered logistic regression models, comparing additional periods of service provision to practice characteristics and to patient satisfaction with access and opening hours in the GP Patient Surveys.
Practices offering Saturday appointments saw a relative decline in demand for additional hours. Practices offering other time periods did not see this. Satisfaction with opening hours improved slightly for practices offering extra appointments, but was not linked to anytime period. The terms and conditions of the extended hours scheme are loosely implemented and this may have limited the apparent effectiveness of the scheme.
Demand for additional opening in primary care is only influenced by Saturday appointments. Satisfaction with opening hours responds to increased capacity, but is not linked to a specific time period.
health care quality, access, and evaluation; health services accessibility; health services needs and demand; physician's practice patterns; primary health care.
Chronic heart failure is a common clinical syndrome that may have different causes. Its incidence and prevalence are predicted to rise substantially over the next 10 years. There are therefore major consequences for resource provision, especially in primary care, where most patients are managed. Chronic heart failure is a serious condition with high morbidity and mortality. There is good evidence to show that treatment with angiotensin-converting enzyme (ACE) inhibitors in patients with left ventricular systolic dysfunction improves symptoms and signs, slows progression of heart failure, reduces hospitalisation rates, and improves survival. Despite this evidence, primary care studies show that patients with heart failure are incorrectly diagnosed and inadequately treated. Most patients present in general practice, and because effective treatment relies on a correct diagnosis, this is a key step in the appropriate management of heart failure. The aim of this paper is to review the evidence about the usefulness of signs, symptoms, and investigations in diagnosing heart failure in primary care. To identify relevant studies for this review, four strategies were used: a MEDLINE search from 1993 to January 1998 using the diagnosis search filter; a MEDLINE search from 1993 to January 1998 using the guideline search filter to locate published heart failure guidelines; a search for review articles in the Cochrane Library; and a check of references in the studies identified. The search terms included MeSH terms and the keywords 'heart failure' and 'diagnosis'. All searches were limited to humans and English language articles. Studies were included in this review on the basis of quality and relevance to primary care. The review shows that symptoms and signs are important because they alert clinicians to the possibility of heart failure as a diagnosis. However, they are not sufficiently specific for confirming left ventricular systolic dysfunction. From the evidence available, a patient with suspected heart failure must have objective tests to confirm the diagnosis. These should include an electrocardiogram and, ideally, an echocardiogram. Further research is also needed on the usefulness of signs and symptoms in primary care, as most studies of heart failure have been conducted in secondary care.
Mental health issues are a core part of the work of primary care and are the second most common reason for consultations. There is some evidence that the quality of primary care mental health provision is variable.
To evaluate the effectiveness of primary care mental health workers with regards to satisfaction with care, mental health symptoms, use of the voluntary sector, and cost effectiveness of care.
Design of study
Cluster randomised controlled trial.
Practices in the Heart of Birmingham Primary Care Trust, Birmingham, England.
Nineteen practices and 368 patients (18 to 65 years of age) with a diagnosis of a new or ongoing common mental health problem were recruited. Sixteen practices and 284 patients completed the trial.
Patients in intervention practices had a higher mean level of general satisfaction than those in control practices (difference between group scores of 8.3, 95% confidence interval = 1.3 to 15.3, P = 0.023). The two groups did not differ in mental health symptom scores or use of the voluntary sector.
For patients with common mental health problems, primary care mental health workers may be effective at increasing satisfaction with an episode of care.
mental health; personal satisfaction; primary health care; treatment effectiveness
Cost-effectiveness studies of lifestyle interventions in people at risk for lifestyle-related diseases, addressing ‘real-world’ implementation, are needed. This study examines the cost-effectiveness of a primary care intervention from a societal perspective, compared with provision of health brochures, alongside a randomized controlled trial.
Adults aged 30-50 years, at risk of type 2 diabetes (T2DM) and/or cardiovascular disease (CVD), were recruited from twelve general practices in The Netherlands. They were randomized to the intervention (n = 314) or control group (n = 308). The intervention consisted of up to six face-to-face counseling sessions with a trained practice nurse, followed by three-monthly sessions by phone. Costs were collected using three-monthly retrospective questionnaires. Quality of life was measured with the EuroQol-5D-3L, at baseline, 6, 12 and 24 months. Nine-year risk of developing T2DM and ten-year risk of CVD mortality were estimated using the ARIC and SCORE formulae, respectively, based on measurements at baseline and 24 months while applying a fixed age of 60 years at both time points.
Small, statistically non-significant differences in effects were found between the intervention and control group with regard to risk scores and Quality Adjusted Life Years (QALYs) gained. The mean difference in costs between the intervention and control group was €-866 (95% confidence interval -2372; 370). The probability that the intervention was cost-effective varied from 93% at €8000/QALY to 88% at €80,000/QALY.
A primary care lifestyle intervention aimed at adults at increased risk of T2DM and/or CVD could result in cost savings over a two-year period. However, due to methodological uncertainty no advice can be given regarding the implementation of the intervention in Dutch general practices.
Current Controlled Trials ISRCTN59358434.
Cost-effectiveness; Cost-utility; General practitioner; Lifestyle counseling; Practice nurse
A survey was made of the diabetic care given by general practitioners in six family practitioner committee areas. Replies were received from 388 practices, representing 1034 principals (effective response rate 69%), serving over two million patients. Fourteen per cent of practices offered mini-clinic facilities for their diabetic patients, although a much greater proportion professed to give either full or shared care to patients in ordinary surgery time. One quarter of practices kept a diabetes register, but fewer had a system of recall for patients to ensure anticipatory care. The barriers which general practitioners most often perceived in the provision of adequate care for diabetics were: lack of time, absence of a recall system and deficiency in their own clinical skills. Seventy seven of the doctors responding to the initial questionnaire participated in an audit of the level of supervision provided for 378 of their diabetic patients. Better levels of supervision of non-insulin dependent diabetics were shown in those practices where diabetes registers were kept, and where special arrangements were made for caring for diabetes. The levels of care provided by those doctors setting aside specific clinic times were not demonstrably superior to those who did not. The findings suggest that provision of support services, particularly expertise in dietetics, would help to increase general practitioners' confidence and enable more of them to improve their care of diabetic patients.
BACKGROUND. Previous studies have demonstrated deficiencies in palliative care in the community. One method of translating the results of research into clinical practice, in order to produce more effective health care, is the development of clinical guidelines. Setting standards for such care has been performed by care teams in both hospital and hospice settings but not in primary care. AIM. This study set out to develop guidelines for primary care teams to follow in the provision of palliative care in the community using facilitated case discussions with the members of such teams, as a form of internal audit. METHOD. Five practices were randomly chosen from the family health services authority medical list. Meetings between the facilitators and primary care teams were held over a period of one year. The teams were asked to describe good aspects of care, areas of concern and suggestions to improve these, in recent cases of patient deaths. RESULTS. In total 56 cases were discussed. All practices felt that cohesive teamwork, coordinated management, early involvement of nursing staff and the identification of a key worker were essential for good terminal care. Concerns arose in clinical and administrative areas but the majority were linked to poor communication, either between patient and professionals within the primary care team or between primary and secondary care. All the positive aspects of care, concerns and suggestions were collated by the facilitators into guidelines for teams to refer to from the initial diagnosis of a terminal illness through to the patient's death and care of the relatives afterwards. CONCLUSION. Developing multidisciplinary as opposed to medical guidelines for palliative care allows primary health care teams to create standards that are acceptable to them and stimulates individuals within the teams to accept responsibility for initiating the change necessary for more effective care. The process of facilitating teams to discuss their work allows for recognition and respect of individuals' roles and more importantly provides shared ownership, an important contributory factor in the implementation of guidelines.
Schizophrenia patients frequently develop somatic co-morbidity. Core tasks for GPs are the prevention and diagnosis of somatic diseases and the provision of care for patients with chronic diseases. Schizophrenia patients experience difficulties in recognizing and coping with their physical problems; however GPs have neither specific management policies nor guidelines for the diagnosis and treatment of somatic co-morbidity in schizophrenia patients. This paper systematically reviews the prevalence and treatment of somatic co-morbidity in schizophrenia patients in general practice.
The MEDLINE, EMBASE, PsycINFO data-bases and the Cochrane Library were searched and original research articles on somatic diseases of schizophrenia patients and their treatment in the primary care setting were selected.
The results of this search show that the incidence of a wide range of diseases, such as diabetes mellitus, the metabolic syndrome, coronary heart diseases, and COPD is significantly higher in schizophrenia patients than in the normal population. The health of schizophrenic patients is less than optimal in several areas, partly due to their inadequate help-seeking behaviour. Current GP management of such patients appears not to take this fact into account. However, when schizophrenic patients seek the GP's help, they value the care provided.
Schizophrenia patients are at risk of undetected somatic co-morbidity. They present physical complaints at a late, more serious stage. GPs should take this into account by adopting proactive behaviour. The development of a set of guidelines with a clear description of the GP's responsibilities would facilitate the desired changes in the management of somatic diseases in these patients.
The prevalence of diabetes mellitus and its complications is higher among First Nations people and people with low socio-economic status (SES). Previous studies in Alberta have shown that provision of care through Primary Care Networks (PCNs) is associated with better quality of care and better outcomes for people with diabetes, possibly because of greater utilization of chronic disease management programs. However, it is unknown whether First Nations individuals and those in lower SES groups experience these benefits.
We used administrative and laboratory data for a population-based cohort analysis of Alberta residents under 65 years of age with diabetes. The primary outcome, assessed over a 1-year period, was admission to hospital or emergency department visit for a diabetes-specific ambulatory care sensitive condition (ACSC). Secondary outcomes were 2 quality-of-care indicators (likelihood of measurement of glycated hemoglobin [HbA1c] and or retinal screening) and 2 measures of health care utilization (visits to specialist and primary care physicians). We used negative binomial regression to determine the association between care within a PCN and hospital admission or emergency department visit for diabetes-specific ACSCs. We also assessed outcomes in 3 populations of interest (individuals receiving a health care subsidy [household income less than $39 250 and not eligible for Income Support], those receiving Income Support, and First Nations individuals) relative to the remainder of the population, controlling for whether care was provided in a PCN and adjusting for several baseline characteristics.
We identified a total of 106 653 patients with diabetes eligible for our study, of whom 43 327 (41%) received care in a PCN. Receiving care through a PCN was associated with lower rates of ACSC-related hospital admission or emergency department visits for all groups of interest, which suggests that PCNs had similar effects across each group. However, regardless of where care was provided, First Nations and low-SES patients had more than twice the adjusted rates of hospital admission or emergency department visits for diabetes-specific ACSCs than the general population and were less likely to receive guideline-recommended care, including measurement of HbA1c and retinal screening.
Care in a PCN was associated with lower risks of hospital admission or emergency department visits for diabetes-specific ACSCs, even within vulnerable groups such as First Nations people and those of low SES. However, differences in outcomes and quality-of-care indicators persisted for First Nations individuals and those of low SES, relative to the general population, irrespective of where care was provided.
Diabetes care is a challenge in rural areas where primary care practices are faced with limited resources, few clinical information systems, and relative isolation from education programs and diabetes centers with multispecialty teams. This report describes an effective field-based approach to support improved care for patients with diabetes in primary care practices in rural states.
A collaborative effort between diabetes prevention and control programs in Montana and Wyoming and the University of North Dakota was established to provide support to rural primary care practices for improvement in diabetes care. Field teams from each state diabetes program approached primary care practices. After assessment and orientation of office staff, a computer-based registry was established in each practice. Baseline data were collected in 1997 in Montana and in 1998 in Wyoming; follow-up occurred on July 31, 2004. Health department staff provided ongoing technical support for implementing and evaluating quality-improvement interventions.
Forty primary care practices, providing care to more than 7000 patients with diabetes, participated in this quality-improvement effort at follow-up. Of the 37 primary care practices participating in the quality-improvement program for 6 or more months at follow-up, there were significant improvements in Montana in rates of hemoglobin A1c testing, blood glucose control, low-density lipoprotein cholesterol testing, foot and dilated retinal examinations, and pneumococcal vaccinations, and there were significant improvements in pneumococcal vaccinations in Wyoming.
A field-based approach in which individual practices maintain and use their own registries for both clinical care and quality improvement with ongoing support is a sustainable and an effective strategy for improving diabetes care for rural populations.
To explore the factors influencing primary care providers’ ability to care for their dying patients in Michigan.
We conducted 16 focus groups to explore the provision of end-of-life care by 7 diverse primary care practices in southeast Michigan. Twenty-eight primary care providers and 22 clinical support staff participated in the study. Interviews were analyzed using thematic analysis.
Primary care providers (PCPs) wanted to care for their dying patients and felt largely competent to provide end-of-life care. They and their staff reported the presence of five structural factors that influenced their ability to do so: (1) continuity of care to help patients make treatment decisions and plan for the end of life; (2) scheduling flexibility and time with patients to address emergent needs, provide emotional support, and conduct meaningful end-of-life discussions; (3) information-sharing with outside providers and within the primary care practice; (4) coordination of care to address patients’ needs quickly; and (5) authority to act on behalf of their patients.
In order to provide end-of-life care, PCPs need structural supports within primary care for continuity of care, flexible scheduling, information-sharing, coordination of primary care, and protection of their authority.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2088-3) contains supplementary material, which is available to authorized users.
primary care practice; palliative care; end of life; qualitative
Many studies have been published over the past decade on patients’ views about the provision of health care. Though there is a high level of migration within the European Union, there are no studies on migrants’ views about the provision of care in the country to which they moved. Given the wide spectrum of primary care in Europe, we hypothesised, without prejudging the outcome, that patients’ confidence in the system they left, used as a proxy of ‘the experience of care’, may influence their preferences regarding specific aspects of care in the host country. The objective of the study was to analyse British migrants’ views on general practice care in France.
A telephone survey was conducted with a random sample of the adult population of British people residing in France. Participants were 437 women and 423 men, aged 18 and over, who had consulted a general practitioner at least once during the past 12 months. The main outcome measures were the responses to the 23-item Europep questionnaire evaluating different aspects of general practice care, using a five-point answering scale with the extremes labelled as “poor” and “excellent”.
Participants were generally satisfied with the GP care provided. The aspects that were rated the highest were related to the doctor-patient relationship which over 80% of the respondents judged as excellent or very good. Some aspects of the organisation of services received relatively negative evaluations. For instance, “waiting time in the waiting room” was evaluated as excellent or very good by only 40% of the respondents. Twenty seven percent of the respondents were not confident in the National Health Service (NHS) when they were still living in UK. After adjusting for age, sex and number of years of residence in France, the respondents who were not confident in the NHS provided a score of “excellent” significantly more frequently (on 11 out of the 23 aspects of care) than did the patients who were confident in the NHS. Most of these aspects concerned the doctor-patient relationship and information and support during the consultation.
British migrants’ views on general practice care in France varied with the degree of confidence they had in the NHS. This finding is in line with the discussion on whether the ‘experience of care’ influences patient satisfaction. A better understanding of this phenomenon should provide valuable insights to make the services more responsive to the patients.
Because the prevalence of type 2 diabetes has increased greatly over the past decade, UK general practitioners have been encouraged to develop services for people with diabetes and to offer structured diabetes care. The resultant shift from secondary care can place considerable demands on primary health care teams. Data were obtained from 108 practices in two English health districts followed up in primary and secondary care. Nearly two-thirds of the people with diabetes were being followed up only in general practice, the remainder in hospital or both. The proportion managed in primary care varied from 5.6% to 94.6%. The settings where diabetes care was most likely to be offered were training practices, practices with good nursing support, practices with a high prevalence of diabetes, and practices in which a high proportion of diabetic patients were controlled by diet or hypoglycaemic agents. Tight control of glycaemia and blood pressure is now seen as important in diabetes, and is best achieved in general practice. This survey revealed large variations in delivery of general-practice diabetes care that need to be addressed by better organization and funding.
Objective To explore how transitions to a palliative care approach are perceived to be managed in acute hospital settings in England.
Design Qualitative study.
Setting Secondary or primary care settings in two contrasting areas of England.
Participants 58 health professionals involved in the provision of palliative care in secondary or primary care.
Results Participants identified that a structured transition to a palliative care approach of the type advocated in UK policy guidance is seldom evident in acute hospital settings. In particular they reported that prognosis is not routinely discussed with inpatients. Achieving consensus among the clinical team about transition to palliative care was seen as fundamental to the transition being effected; however, this was thought to be insufficiently achieved in practice. Secondary care professionals reported that discussions about adopting a palliative care approach to patient management were not often held with patients; primary care professionals confirmed that patients were often discharged from hospital with “false hope” of cure because this information had not been conveyed. Key barriers to ensuring a smooth transition to palliative care included the difficulty of “standing back” in an acute hospital situation, professional hierarchies that limited the ability of junior medical and nursing staff to input into decisions on care, and poor communication.
Conclusion Significant barriers to implementing a policy of structured transitions to palliative care in acute hospitals were identified by health professionals in both primary and secondary care. These need to be addressed if current UK policy on management of palliative care in acute hospitals is to be established.
To determine whether models of primary care service delivery differ in their provision of family-centred care (FCC) and to identify practice characteristics associated with FCC.
Primary care practices in Ontario (ie, 35 salaried community health centres, 35 fee-for-service practices, 32 capitation-based health service organizations, and 35 blended remuneration family health networks) that belong to 4 models of primary care service delivery.
A total of 137 practices, 363 providers, and 5144 patients.
Main outcome measures
Measures of FCC in patient and provider surveys were based on the Primary Care Assessment Tool. Statistical analyses were conducted using linear mixed regression models and generalized estimating equations.
Patient-reported FCC scores were high and did not vary significantly by primary care model. Larger panel size in a practice was associated with lower odds of patients reporting FCC. Provider-reported FCC scores were significantly higher in community health centres than in family health networks (P = .035). A larger number of nurse practitioners and clinical services on-site were both associated with higher FCC scores, while scores decreased as the number of family physicians in a practice increased and if practices were more rural.
Based on provider and patient reports, primary care reform strategies that encourage larger practices and more patients per family physician might compromise the provision of FCC, while strategies that encourage multidisciplinary practices and a range of services might increase FCC.
BACKGROUND: Primary care is being expected to expand the range of services it provides, and to take on many of the tasks traditionally provided in secondary care. At the same time, general practitioners (GPs) will become increasingly responsible for assessing their patients' health care needs and commissioning care from other providers. This article describes an approach taken in one general practice to meet these difficult challenges. AIM: To examine whether information on health and health care needs, when used as the basis for a priority setting exercise, can provide a useful first step in planning primary care provision within a practice. METHOD: A three-stage process of information-gathering from a number of sources, including continuous data recording of patient contacts and a postal survey of all adults registered with the practice, identification of key findings and discussion of associated issues, and priority setting of proposals for practice development using the nominal group technique. RESULTS: Continuous data recording of patient contacts with GPs and the practice nurse provided data on 4489 GP contacts with 2027 patients, 1000 district nurse contacts with 101 patients, and 361 health visitor contacts with 172 clients. More than 70% of patient records had been computerized, with 600 diagnostic READ codes identified and 11,500 separate entries made. The socioeconomic and health survey questionnaire achieved an 84% response rate. Following the priority-setting exercise, 28 proposed practice developments were identified. These were reduced to a final list of eight. CONCLUSION: A comprehensive method of practice-based needs assessment, when used as the basis for some form of priority setting, has great potential in helping to plan primary care services within a practice. The success of such initiatives will require a substantial investment of resources in primary care and fundamental changes to the way in which primary care is funded.
Redesigning care has been proposed as a lever for improving chronic illness care. Within primary care, diabetes care is the most widespread example of restructured integrated care. Our goal was to assess to what extent important aspects of restructured care such as multidisciplinary teamwork and different types of organizational culture are associated with high quality diabetes care in small office-based general practices.
We conducted cross-sectional analyses of data from 83 health care professionals involved in diabetes care from 30 primary care practices in the Netherlands, with a total of 752 diabetes mellitus type II patients participating in an improvement study. We used self-reported measures of team climate (Team Climate Inventory) and organizational culture (Competing Values Framework), and measures of quality of diabetes care and clinical patient characteristics from medical records and self-report. We conducted multivariate analyses of the relationship between culture, climate and HbA1c, total cholesterol, systolic blood pressure and a sum score on process indicators for the quality of diabetes care, adjusting for potential patient- and practice level confounders and practice-level clustering.
A strong group culture was negatively associated to the quality of diabetes care provided to patients (β = -0.04; p = 0.04), whereas a more 'balanced culture' was positively associated to diabetes care quality (β = 5.97; p = 0.03). No associations were found between organizational culture, team climate and clinical patient outcomes.
Although some significant associations were found between high quality diabetes care in general practice and different organizational cultures, relations were rather marginal. Variation in clinical patient outcomes could not be attributed to organizational culture or teamwork. This study therefore contributes to the discussion about the legitimacy of the widespread idea that aspects of redesigning care such as teamwork and culture can contribute to higher quality of care. Future research should preferably combine quantitative and qualitative methods, focus on possible mediating or moderating factors and explore the use of instruments more sensitive to measure such complex constructs in small office-based practices.
In January 2010, the American Diabetes Association recommended the use of hemoglobin A1c (Hgb A1c) to screen and diagnose diabetes. This study explored the prevalence and clinical context of Hgb A1c tests done for non-diabetic primary care patients for the three years prior to the release of the new guidelines. We sought to determine the provision of tests in non-diabetic patients age 19 or over, patients age 45 and over (eligible for routine diabetes screening), the annual change in the rate of this screening test, and the patient characteristics associated with the provision of Hgb A1c screening.
We conducted a retrospective study using data routinely collected in Electronic Medical Records. The participants were thirteen community-based family physicians in Toronto, Ontario. We calculated the proportion of non diabetic patients who had at least one Hbg A1c done in three years. We used logistic generalized estimating equation with year treated as a continuous variable to test for a non-zero slope in yearly Hbg A1c provision. We modelled screening using multivariable logistic regression.
There were 11,792 non-diabetic adults. Of these, 1,678 (14.2%; 95%CI 13.6%-14.9%) had at least one Hgb A1c test done; this was higher for patients 45 years of age or older (20.2%; 95% CI 19.3% - 21.2%). The proportion of non-diabetic patients with an A1c test increased from 5.2% in 2007 to 8.8% in 2009 (p < 0.0001 for presence of slope). Factors associated with significantly greater adjusted odds ratios of having the test done included increasing diastolic blood pressure, increasing fasting glucose, increasing body mass index, increasing age, as well as male gender and presence of hypertension, but not smoking status or LDL cholesterol. Patients living in the highest income quintile neighbourhoods had significantly lower odds ratios of having this test done than those in the lowest quintile (p < 0.001).
A large and increasing proportion of the non-diabetic patients we studied have had an Hgb A1c for screening prior to guidelines recommending the test for this purpose. Several risk factors for cardiovascular disease or diabetes were associated with the provision of the Hgb A1c. Early uptake of the test may represent appropriate utilization.