Although collaborative team models (CTM) improve care processes and health outcomes, their diffusion poses challenges related to difficulties in securing their adoption by primary care clinicians (PCPs). The objectives of this study are to understand: (1) how the perceived characteristics of a CTM influenced clinicians' decision to adopt -or not- the model; and (2) the model's diffusion process.
We conducted a longitudinal case study based on the Diffusion of Innovations Theory. First, diffusion curves were developed for all 175 PCPs and 59 nurses practicing in one borough of Paris. Second, semi-structured interviews were conducted with a representative sample of 40 PCPs and 15 nurses to better understand the implementation dynamics.
Diffusion curves showed that 3.5 years after the start of the implementation, 100% of nurses and over 80% of PCPs had adopted the CTM. The dynamics of the CTM's diffusion were different between the PCPs and the nurses. The slopes of the two curves are also distinctly different. Among the nurses, the critical mass of adopters was attained faster, since they adopted the CTM earlier and more quickly than the PCPs. Results of the semi-structured interviews showed that these differences in diffusion dynamics were mostly founded in differences between the PCPs' and the nurses' perceptions of the CTM's compatibility with norms, values and practices and its relative advantage (impact on patient management and work practices). Opinion leaders played a key role in the diffusion of the CTM among PCPs.
CTM diffusion is a social phenomenon that requires a major commitment by clinicians and a willingness to take risks; the role of opinion leaders is key. Paying attention to the notion of a critical mass of adopters is essential to developing implementation strategies that will accelerate the adoption process by clinicians.
Primary care; Primary care physician; Nurses; Chronic disease; Collaboration; Health service research; Diffusion of innovation
In a General Practitioner (GP) setting, preventative medicine is reported as the predominant source of health care for the well-child. However, the role of the GP in well-child health care is not well understood in Australia. The aim of this study was to describe the role of the GP in providing services for well-children and families in Australia.
This was a qualitative descriptive study. Face-to-face interviews were held with 23 GPs to identify their role in the provision of well-child health care. Participants worked in a variety of general practice settings and 21 of the 23 GPs worked in the Greater Western Sydney area.
Five main themes were identified in the analysis: ‘prevention is better than cure’, ‘health promotion: the key messages’, ‘working with families’, ‘working with other health professionals’, and ‘barriers to the delivery of well-child health services’.
Participating GPs had a predominantly preventative focus, but in the main well-child care was opportunistic rather than proactive. The capacity to take a primary preventative approach to the health of children and families by GPs is limited by the increasing demands to manage chronic disease. Serious consideration should be given to developing collaborative models of care where GPs are joined up with services funded by State and Territory governments in Australia, such as the universal maternal child and family health nursing services that have well children and families as their prime focus.
General practitioner; Well-child; Family; Role; Australian
Family physicians perceive that gut feelings, i.e. a ‘sense of reassurance’ or a ‘sense of alarm’, play a substantial role in diagnostic reasoning. A measuring instrument is desirable for further research. Our objective is to validate a questionnaire measuring the presence of gut feelings in diagnostic reasoning.
We constructed 16 case vignettes from real practice situations and used the accompanying ‘sense of reassurance’ or the ‘sense of alarm’ as reference labels. Based on the results of an initial study (26 family physicians), we divided the case vignettes into a group involving a clear role for the sense of reassurance or the sense of alarm and a group involving an ambiguous role. 49 experienced family physicians evaluated each 10 vignettes using the questionnaire. Construct validity was assessed by testing hypotheses and an internal consistency procedure was performed.
As hypothesized we found that the correlations between the reference labels and corresponding items were high for the clear-case vignettes (0.59 – 0.72) and low for the ambiguous-case vignettes (0.08 – 0.23). The agreement between the classification in clear sense of reassurance, clear sense of alarm and ambiguous case vignettes as derived from the initial study and the study population’s judgments was substantial (Kappa = 0.62). Factor analysis showed one factor with opposites for sense of reassurance and sense of alarm items. The questionnaire’s internal consistency was high (0.91). We provided a linguistic validated English-language text of the questionnaire.
The questionnaire appears to be valid. It enables quantitative research into the role of gut feelings and their diagnostic value in family physicians’ diagnostic reasoning.
Gut feelings; Family medicine; General practitioners; Diagnostic reasoning; Questionnaire; Construct validation; Medical decision-making; Medical problem-solving; Intuition; Clinical reasoning
Academic detailing is an interactive, convenient, and user-friendly approach to delivering non-commercial education to healthcare clinicians. While evidence suggests academic detailing is associated with improvements in prescribing behavior, uncertainty exists about generalizability and scalability in diverse settings. Our study evaluates different models of delivering academic detailing in a rural family medicine setting.
We conducted a pilot project to assess the feasibility, effectiveness, and satisfaction with academic detailing delivered face-to-face as compared to a modified approach using distance-learning technology. The recipients were four family medicine clinics within the Oregon Rural Practice-based Research Network (ORPRN). Two clinics were allocated to receive face-to-face detailing and two received outreach through video conferencing or asynchronous web-based outreach. Surveys at midpoint and completion were used to assess effectiveness and satisfaction.
Each clinic received four outreach visits over an eight month period. Topics included treatment-resistant depression, management of atypical antipsychotics, drugs for insomnia, and benzodiazepine tapering. Overall, 90% of participating clinicians were satisfied with the program. Respondents who received in person detailing reported a higher likelihood of changing their behavior compared to respondents in the distance detailing group for five of seven content areas. While 90%-100% of respondents indicated they would continue to participate if the program were continued, the likelihood of participation declined if only distance approaches were offered.
We found strong support and satisfaction for the program among participating clinicians. Participants favored in-person approaches to distance interactions. Future efforts will be directed at quantitative methods for evaluating the economic and clinical effectiveness of detailing in rural family practice settings.
Immigrants make up one fifth of the Canadian population and this number continues to grow. Adequate access to primary health care is important for this population but it is not clear if this is being achieved. This study explored patient reported access to primary health care of a population of immigrants in Ontario, Canada who were users of the primary care system and compared this with Canadian-born individuals; and by model of primary care practice.
This study uses data from the Comparison of Models of Primary Care Study (COMP-PC), a mixed-methods, practice-based, cross-sectional study that collected information from patients and providers in 137 primary care practices across Ontario, Canada in 2005-2006. The practices were randomly sampled to ensure an equal number of practices in each of the four dominant primary care models at that time: Fee-For-Service, Community Health Centres, and the two main capitation models (Health Service Organization and Family Health Networks). Adult patients of participating practices were identified when they presented for an appointment and completed a survey in the waiting room. Three measures of access were used, all derived from the patient survey: First Contact Access, First Contact Utilization (both based on the Primary Care Assessment Tool) and number of self-reported visits to the practice in the past year.
Of the 5,269 patients who reported country of birth 1,099 (20.8%) were born outside of Canada. In adjusted analysis, recent immigrants (arrival in Canada within the past five years) and immigrants in Canada for more than 20 years were less likely to report good health compared to Canadian-born (Odds ratio 0.58, 95% CI 0.36,0.92 and 0.81, 95% CI 0.67,0.99). Overall, immigrants reported equal access to primary care services compared with Canadian-born. Within immigrant groups recently arrived immigrants had similar access scores to Canadian-born but reported 5.3 more primary care visits after adjusting for health status. Looking across models, recent immigrants in Fee-For-Service practices reported poorer access and fewer primary care visits compared to Canadian-born.
Overall, immigrants who were users of the primary care system reported a similar level of access as Canadian-born individuals. While recent immigrants are in poorer health compared with Canadian-born they report adequate access to primary care. The differences in access for recently arrived immigrants, across primary care models suggests that organizational features of primary care may lead to inequity in access.
Primary health care; Access to health care; Immigrants; Canada
Patient safety is vital in patient care. There is a lack of studies on medical errors in primary care settings. The aim of the study is to determine the extent of diagnostic inaccuracies and management errors in public funded primary care clinics.
This was a cross-sectional study conducted in twelve public funded primary care clinics in Malaysia. A total of 1753 medical records were randomly selected in 12 primary care clinics in 2007 and were reviewed by trained family physicians for diagnostic, management and documentation errors, potential errors causing serious harm and likelihood of preventability of such errors.
The majority of patient encounters (81%) were with medical assistants. Diagnostic errors were present in 3.6% (95% CI: 2.2, 5.0) of medical records and management errors in 53.2% (95% CI: 46.3, 60.2). For management errors, medication errors were present in 41.1% (95% CI: 35.8, 46.4) of records, investigation errors in 21.7% (95% CI: 16.5, 26.8) and decision making errors in 14.5% (95% CI: 10.8, 18.2). A total of 39.9% (95% CI: 33.1, 46.7) of these errors had the potential to cause serious harm. Problems of documentation including illegible handwriting were found in 98.0% (95% CI: 97.0, 99.1) of records. Nearly all errors (93.5%) detected were considered preventable.
The occurrence of medical errors was high in primary care clinics particularly with documentation and medication errors. Nearly all were preventable. Remedial intervention addressing completeness of documentation and prescriptions are likely to yield reduction of errors.
Medical errors; Diagnostic errors; Medication errors; Primary health care
Diabetes is an important contributor to the burden of disease in South Africa and prevalence rates as high as 33% have been recorded in Cape Town. Previous studies show that quality of care and health outcomes are poor. The development of an effective education programme should impact on self-care, lifestyle change and adherence to medication; and lead to better control of diabetes, fewer complications and better quality of life.
Trial design: Pragmatic cluster randomized controlled trial
Participants: Type 2 diabetic patients attending 45 public sector community health centres in Cape Town
Interventions: The intervention group will receive 4 sessions of group diabetes education delivered by a health promotion officer in a guiding style. The control group will receive usual care which consists of ad hoc advice during consultations and occasional educational talks in the waiting room.
Objective: To evaluate the effectiveness of the group diabetes education programme
Outcomes: Primary outcomes: diabetes self-care activities, 5% weight loss, 1% reduction in HbA1c. Secondary outcomes: self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c, mean total cholesterol, quality of life
Randomisation: Computer generated random numbers
Blinding: Patients, health promoters and research assistants could not be blinded to the health centre’s allocation
Numbers randomized: Seventeen health centres (34 in total) will be randomly assigned to either control or intervention groups. A sample size of 1360 patients in 34 clusters of 40 patients will give a power of 80% to detect the primary outcomes with 5% precision. Altogether 720 patients were recruited in the intervention arm and 850 in the control arm giving a total of 1570.
The study will inform policy makers and managers of the district health system, particularly in low to middle income countries, if this programme can be implemented more widely.
Pan African Clinical Trial Registry PACTR201205000380384
Diabetes; Group education; Health education; Motivational interviewing; Mid-level health workers; South Africa; Primary care
Most Canadians receive basic health services from a family physician and these physicians are particularly critical in the management of chronic disease. Canada, however, has an endemic shortage of family physicians. Physician shortages and turnover are particularly acute in rural regions, leaving their residents at risk of needing to transition between family physicians. The knowledge base about how patients manage transitioning in a climate of scarcity remains nascent. The purpose of this study is to explore the experience of transitioning for chronically ill, rurally situated Canadian women to provide insight into if and how the system supports transitioning patients and to identify opportunities for enhancing that support.
Chronically ill women managing rheumatic diseases residing in two rural counties in the province of Ontario were recruited to participate in face-to-face, semi-structured interviews. Interview transcripts were analysed thematically to identify emergent themes associated with the transitioning experience.
Seventeen women participated in this study. Ten had experienced transitioning and four with long-standing family physicians anticipated doing so soon. The remaining three expressed concerns about transitioning. Thematic analysis revealed the presence of a transitioning trajectory with three phases. The detachment phase focused on activities related to the termination of a physician-patient relationship, including haphazard notification tactics and the absence of referrals to replacement physicians. For those unable to immediately find a new doctor, there was a phase of unattachment during which patients had to improvise ways to receive care from alternative providers or walk-in clinics. The final phase, attachment, was characterized by acceptance into the practice of a new family physician.
Participants often found transitioning challenging, largely due to perceived gaps in support from the health care system. Barriers to a smooth transition included inadequate notification procedures, lack of formal assistance finding new physicians, and unsatisfactory experiences seeking care during unattachment. The participants’ accounts reveal opportunities for a stronger system presence during transition and a need for further research into alternative models of primary care delivery.
Family medicine; Canada; Unattached patients; Continuity; Attachment; Rural
Revalidation for UK doctors is expected to be introduced from late 2012. For general practitioners (GPs), this entails collecting supporting information to be submitted and assessed in a revalidation portfolio every five years. The aim of this study was to explore the feasibility of GPs working in secure environments to collect supporting information for the Royal College of General Practitioners’ (RCGP) proposed revalidation portfolio.
We invited GPs working in secure environments in England to submit items of supporting information collected during the previous 12 months using criteria and standards required for the proposed RCGP revalidation portfolio and complete a GP issues log. Initial focus groups and initial and follow-up semi-structured face-to-face and telephone interviews were held to explore GPs’ views of this process. Quantitative and qualitative data were analysed using descriptive statistics and identifying themes respectively.
Of the 50 GPs who consented to participate in the study, 20 submitted a portfolio. Thirty-eight GPs participated in an initial interview, nine took part in a follow-up interview and 17 completed a GP issues log. GPs reported difficulty in collecting supporting information for valid patient feedback, full-cycle clinical audits and evidence for their extended practice role(s) as sessional practitioners in the high population turnover custodial environment. Peripatetic practitioners experienced more difficulty than their institution based counterparts collating this evidence.
GPs working in secure environments may experience difficulties in collecting the newer types of supporting information for the proposed RCGP revalidation portfolio primarily due to their employment status within a non-medical environment and characteristics of the detainee population. Increased support from secure environment service commissioners and employers will be a prerequisite for these practitioners to enable them to re-license using the RCGP revalidation proposals.
Revalidation; Re-licensing; Medical continuing professional development; General practitioners; Family physicians; Sessional GPs; Salaried GPs; Secure environments; Prisons
With an average prescription rate of 50%, in German primary care antibiotics are still too frequently prescribed for respiratory tract infections. The over-prescription of antibiotics is often explained by perceived patient pressure and fears of a complicated disease progression. The CHANGE-2 trial will test the effectiveness of two interventions to reduce the rate of inappropriate antibiotic prescriptions for adults and children suffering from respiratory tract infections in German primary care.
The study is a three-arm cluster-randomized controlled trial that measures antibiotic prescription rates over three successive winter periods and reverts to administrative data of the German statutory health insurance company AOK. More than 30,000 patients in two regions of Germany, who visit their general practitioner or pediatrician for respiratory tract infections will be included. Interventions are: A) communication training for general practitioners and pediatricians and B) intervention A plus point-of-care testing. Both interventions are tested against usual care. Outcome measure is the physicians’ antibiotic prescription rate for respiratory tract infections derived from data of the health insurance company AOK. Secondary outcomes include reconsultation rate, complications, and hospital admissions.
Major aim of the study is to improve the process of decision-making and to ensure that patients who are likely to benefit from antibiotics are treated accordingly. Our approach is simple to implement and might be used rapidly among general practitioners and pediatricians. We expect the results of this trial to have major impact on antibiotic prescription strategies and practices in Germany, both among general practitioners and pediatricians.
The study is registered at the Current Controlled Trials Ltd (ISRCTN01559032)
Antibiotic prescribing; Respiratory tract infections; Primary care; Randomized controlled trial
The purpose of this study is to better understand differences in diabetes self-management, specifically needs, barriers and challenges among men and women living with type 2 diabetes mellitus (T2DM).
35 participants were recruited from a diabetes education center (DEC) in Toronto, Canada. Five focus groups and nine individual interviews were conducted to explore men and women's diabetes self-management experiences.
The average age of participants was 57 years and just over half (51.4%) were female. Analyses revealed five themes: disclosure and identity as a person living with diabetes; self-monitoring of blood glucose (SMBG); diet struggles across varying contexts; utilization of diabetes resources; and social support. Women disclosed their diabetes more readily and integrated management into their daily lives, whereas men were more reluctant to tell friends and family about their diabetes and were less observant of self-management practices in social settings. Men focused on practical aspects of SMBG and experimented with various aspects of management to reduce reliance on medications whereas women focused on affective components of SMBG. Women restricted foods from their diets perceived as prohibited whereas many men moderated their intake of perceived unhealthy foods, except in social situations. Women used socially interactive resources, like education classes and support groups whereas men relied more on self-directed learning but also described wanting more guidance to help navigate the healthcare system. Finally, men and women reported wanting physician support for both affective and practical aspects of self-management.
Our findings highlight the differences in needs and challenges of diabetes self-management among men and women, which may inform gender-sensitive diabetes, care, counseling and support.
Diabetes; Self-management; Type 2 Diabetes Mellitus; Sex; Gender
In this paper a specialist in general practice is referred to as a general practitioner (GP). In Finland only half of all GPs work as a health centre physician. The present aim was to establish what the working places of specializing and specialized physicians in general practice are, and where they assume they will work in the future.
The study population comprised 5,357 physicians licensed in Finland during the years 1977–1996. Altogether 2,956 questionnaires were returned, a response rate of 55.2%. Those either specializing (GP trainees, n=133) or already having specialized (GPs, n=426) in general practice were included in the study. Respondents were asked what kind of physician’s work they would most preferably do. They were further asked what work they assumed they would be doing in the year 2020.
Altogether 72% were working in public primary health centres and 14% in the private sector. Of GPs 53% and of GP trainees 70% would most preferably work in health centres. Of GPs 14% would most preferably work as private practitioners and 9% as occupational health physicians. Sixteen per cent assumed they would be working as private practitioners and 35% assumed they would be retired in the year 2020. Of GP trainees 57% assumed they would be working as health centre physicians in 2020.
According to the present findings many experienced GPs will leave their work as a health centre physician. Moreover, several GP trainees do not consider health centre physician’s work as a long-term career option. These trends may in the future reflect a recruiting problem in many primary health centres.
GP; Specializing; Health centre; Private practitioner; Workforce
Growing interest in the promise of patient-centered care has led to numerous health care innovations, including the patient-centered medical home, shared decision-making, and payment reforms. How best to vet and adopt innovations is an open question. Washington State has been a leader in health care reform and is a rich laboratory for patient-centered innovations. We sought to understand the process of patient-centered care innovation undertaken by innovative health care organizations – from strategic planning to goal selection to implementation to maintenance.
We conducted key-informant interviews with executives at five health plans, five provider organizations, and ten primary care clinics in Washington State. At least two readers of each interview transcript identified themes inductively; final themes were determined by consensus.
Innovation in patient-centered care was a strategic objective chosen by nearly every organization in this study. However, other goals were paramount: cost containment, quality improvement, and organization survival. Organizations commonly perceived effective chronic disease management and integrated health information technology as key elements for successful patient-centered care innovation. Inertia, resource deficits, fee-for-service payment, and regulatory limits on scope of practice were cited as barriers to innovation, while organization leadership, human capital, and adaptive culture facilitated innovation.
Patient-centered care innovations reflected organizational perspectives: health plans emphasized cost-effectiveness while providers emphasized health care delivery processes. Health plans and providers shared many objectives, yet the two rarely collaborated to achieve them. The process of innovation is heavily dependent on organizational culture and leadership. Policymakers can improve the pace and quality of patient-centered innovation by setting targets and addressing conditions for innovation.
Patient-centered care; Primary care; Health care reform
Depression is common in coronary heart disease (CHD) and increases the incidence of coronary symptoms and death in CHD patients. Interventions feasible for use in primary care are needed to improve both mood and cardiac outcomes. The UPBEAT-UK programme of research has been funded by the NHS National Institute for Health Research (NIHR) to explore the relationship between CHD and depression and to develop a new intervention for use in primary care.
Using the Medical Research Council (MRC) guidelines for developing and evaluating complex interventions, we conducted a systematic review and qualitative research to develop a primary care-based nurse-led intervention to improve mood and cardiac outcomes in patients with CHD and depression. Iterative literature review was used to synthesise our empirical work and to identify evidence and theory to inform the intervention.
We developed a primary care-based nurse-led personalised care intervention which utilises elements of case management to promote self management. Following biopsychosocial assessment, a personalised care plan is devised. Nurses trained in behaviour change techniques facilitate patients to address the problems important to them. Identification and utilisation of existing resources is promoted. Nurse time is conserved through telephone follow up.
Application of the MRC framework for complex interventions has allowed us to develop an evidence based intervention informed by patient and clinician preferences and established theory. The feasibility and acceptability of this intervention is now being tested further in an exploratory trial.
Complex intervention; Personalised care; Coronary heart disease; Depression; Primary care
This study investigates the efficacy of a complex multifaceted intervention aiming at increasing the quality of care of GPs for patients with multimorbidity. In its core, the intervention aims at enhancing the doctor-patient-dialogue and identifying the patient’s agenda and needs. Also, a medication check is embedded. Our primary hypothesis is that a more patient-centred communication will reduce the number of active pharmaceuticals taken without impairing the patients’ quality of life. Secondary hypotheses include a better knowledge of GPs about their patients’ medication, a higher patient satisfaction and a more effective and/or efficient health care utilization.
Multi-center, parallel group, cluster randomized controlled clinical trial in GP surgeries. Inclusion criteria: Patients aged 65–84 years with at least 3 chronic conditions. Intervention: GPs allocated to this group will receive a multifaceted educational intervention on performing a narrative doctor-patient dialogue reflecting treatment targets and priorities of the patient and on performing a narrative patient-centred medication review. During the one year intervention GPs will have a total of three conversations à 30 minutes with the enrolled patients. Control: Care as usual. Follow-up per patient: 14 months after baseline interview. Primary efficacy endpoints: Differences in medication intake and health related quality of life between baseline and follow-up in the intervention compared to the control group. Randomization: Computer-generated by an independent institute. It will be performed successively when patient recruitment in the respective surgery is finished. Blinding: Participants (GPs and patients) will not be blinded to their assignment but will be unaware of the study hypotheses or outcome measures.
There is growing evidence that the phenomenon of polypharmacy and low quality of drug use is substantially due to mis-communication (or non-communication) in the doctor patient interaction. We assume that the number of pharmaceutical agents taken can be reduced by a communicational intervention and that this will not impair the patients’ health-related quality of life. Improving communication is a core issue of future interventions, especially for patients with multimorbidity.
Current Controlled Trials ISRCTN46272088.
Multimorbidity; Primary care; Randomised controlled trial; Polypharmacy; Narrative based medicine
Lower social economic status (SES) is related to an elevated cardiovascular (CV) risk. A pro-active primary prevention CV screening approach in general practice (GP) might be effective in a region with a low mean SES. This approach, supported by a regional GP laboratory, was investigated on feasibility, attendance rate and proportion of persons identified with an elevated risk.
In a region with a low mean SES, men and women aged ≥50/55 years, respectively, were invited for cardiovascular risk profiling, based on SCORE 10-year risk of fatal cardiovascular disease and additional risk factors (family history, weight and end organ damage). Screening was performed by laboratory personnel, at the GP practice. Treatment advice was based on Dutch GP guidelines for cardiovascular risk management. Response rates were compared to those in five other practices, using the same screening method.
521 persons received invitations, 354 (68%) were interested, 33 did not attend and 43 were not further analysed because of already known diabetes/cardiovascular disease. Eventually 278 risk profiles were analysed, of which 60% had a low cardiovascular risk (SCORE-risk <5%). From the 40% participants with a SCORE-risk ≥5%, 60% did not receive medication yet for hypertension/hypercholesterolemia. In the other five GPs response rates were comparable to the currently described GP.
Screening in GP in a low SES area, performed by a laboratory service, was feasible, resulted in high attendance, and identification and treatment advice of many new persons at risk for cardiovascular disease.
General practice; Socio-economic status (SES); Cardiovascular risk management; Screening
With increasing age and longevity, the rising number of frail elders with complex and numerous health-related needs demands a coordinated health care delivery system integrating cure, care and welfare. Studies on the effectiveness of such comprehensive chronic care models targeting frail elders show inconclusive results. The CareWell-primary care program is a complex intervention targeting community-dwelling frail elderly people, that aims to prevent functional decline, improve quality of life, and reduce or postpone hospital and nursing home admissions of community dwelling frail elderly.
The CareWell-primary care study includes a (cost-) effectiveness study and a comprehensive process evaluation. In a one-year pragmatic, cluster controlled trial, six general practices are non-randomly recruited to adopt the CareWell-primary care program and six control practices will deliver ‘care as usual’. Each practice includes a random sample of fifty frail elders aged 70 years or above in the cost-effectiveness study. A sample of patients and informal caregivers and all health care professionals participating in the CareWell-primary care program are included in the process evaluation. In the cost-effectiveness study, the primary outcome is the level of functional abilities as measured with the Katz-15 index. Hierarchical mixed-effects regression models / multilevel modeling approach will be used, since the study participants are nested within the general practices. Furthermore, incremental cost-effectiveness ratios will be calculated as costs per QALY gained and as costs weighed against functional abilities. In the process evaluation, mixed methods will be used to provide insight in the implementation degree of the program, patients’ and professionals’ approval of the program, and the barriers and facilitators to implementation.
The CareWell-primary care study will provide new insights into the (cost-) effectiveness, feasibility, and barriers and facilitators for implementation of this complex intervention in primary care.
The CareWell-primary care study is registered in the ClinicalTrials.gov Protocol Registration System: NCT01499797
Frail elderly; Complex intervention; Integrated care; Functional status; Cost-effectiveness; Implementation; Process evaluation; Primary care
Type 2 Diabetes Mellitus (DM) is a common chronic disease associated with multiple clinical complications. Management guidelines have been established which recommend a risk-stratified approach to managing these patients in primary care. This study aims to evaluate the quality of care (QOC) and effectiveness of a multi-disciplinary risk assessment and management programme (RAMP) for type 2 diabetic patients attending government-funded primary care clinics in Hong Kong. The evaluation will be conducted using a structured and comprehensive evidence-based evaluation framework.
For evaluation of the quality of care, a longitudinal study will be conducted using the Action Learning and Audit Spiral methodologies to measure whether the pre-set target standards for criteria related to the structure and process of care are achieved. Each participating clinic will be invited to complete a Structure of Care Questionnaire evaluating pre-defined indicators which reflect the setting in which care is delivered, while process of care will be evaluated against the pre-defined indicators in the evaluation framework.
Effectiveness of the programme will be evaluated in terms of clinical outcomes, service utilization outcomes, and patient-reported outcomes. A cohort study will be conducted on all eligible diabetic patients who have enrolled into RAMP for more than one year to compare their clinical and public service utilization outcomes of RAMP participants and non-participants. Clinical outcome measures will include HbA1c, blood pressure (both systolic and diastolic), lipids (low-density lipoprotein cholesterol) and future cardiovascular diseases risk prediction; and public health service utilization rate will include general and specialist outpatient, emergency department attendances, and hospital admissions annually within 5 years. For patient-reported outcomes, a total of 550 participants and another 550 non-participants will be followed by telephone to monitor quality of life, patient enablement, global rating of change in health and private health service utilization at baseline, 6, 12, 36 and 60 months.
The quality of care and effectiveness of the RAMP in enhancing the health for patients with type 2 diabetes will be determined. Possible areas for quality enhancement will be identified and standards of good practice can be established. The information will be useful in guiding service planning and policy decision making.
Type 2 diabetes mellitus; Quality of life; Primary care; Prevention; Primary health care; Management programme; Risk prediction; Risk stratification
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.
General practitioners often care for patients with several concurrent chronic medical conditions (multimorbidity). Recent data suggest that multimorbidity might be observed more often than isolated diseases in primary care. We explored the age- and gender-related prevalence of multimorbidity and compared these estimates to the prevalence estimates of other common specific diseases found in Swiss primary care.
We analyzed data from the Swiss FIRE (Family Medicine ICPC Research using Electronic Medical Record) project database, representing a total of 509,656 primary care encounters in 98,152 adult patients between January 1, 2009 and July 31, 2011. For each encounter, medical problems were encoded using the second version of the International Classification of primary Care (ICPC-2). We defined chronic health conditions using 147 pre-specified ICPC-2 codes and defined multimorbidity as 1) two or more chronic health conditions from different ICPC-2 rubrics, 2) two or more chronic health conditions from different ICPC-2 chapters, and 3) two or more medical specialties involved in patient care. We compared the prevalence estimates of multimorbidity defined by the three methodologies with the prevalence estimates of common diseases encountered in primary care.
Overall, the prevalence estimates of multimorbidity were similar for the three different definitions (15% [95%CI 11-18%], 13% [95%CI 10-16%], and 14% [95%CI 11-17%], respectively), and were higher than the prevalence estimates of any specific chronic health condition (hypertension, uncomplicated 9% [95%CI 7-11%], back syndrome with and without radiating pain 6% [95%CI 5-7%], non-insulin dependent diabetes mellitus 3% [95%CI 3-4%]), and degenerative joint disease 3% [95%CI 2%-4%]). The prevalence estimates of multimorbidity rose more than 20-fold with age, from 2% (95%CI 1-2%) in those aged 20–29 years, to 38% (95%CI 31-44%) in those aged 80 or more years. The prevalence estimates of multimorbidity were similar for men and women (15% vs. 14%, p=0.288).
In primary care, prevalence estimates of multimorbidity are higher than those of isolated diseases. Among the elderly, more than one out of three patients suffer from multimorbidity. Management of multimorbidity is a principal concern in this vulnerable patient population.
Multimorbidity; Chronic medical conditions; Prevalence; Primary care; Age; Gender; Swiss; FIRE
Lifestyle is one of the main determinants of people’s health. It is essential to find the most effective prevention strategies to be used to encourage behavioral changes in their patients. Many theories are available that explain change or adherence to specific health behaviors in subjects. In this sense the named Motivational Interviewing has increasingly gained relevance. Few well-validated instruments are available for measuring doctors’ communication skills, and more specifically the Motivational Interviewing.
The hypothesis of this study is that the Scale for Measuring Motivational Interviewing Skills (EVEM questionnaire) is a valid and reliable instrument for measuring the primary care professionals skills to get behavior change in patients. To test the hypothesis we have designed a prospective, observational, multi-center study to validate a measuring instrument. –Scope: Thirty-two primary care centers in Spain. -Sampling and Size: a) face and consensual validity: A group composed of 15 experts in Motivational Interviewing. b) Assessment of the psychometric properties of the scale; 50 physician- patient encounters will be videoed; a total of 162 interviews will be conducted with six standardized patients, and another 200 interviews will be conducted with 50 real patients (n=362). Four physicians will be specially trained to assess 30 interviews randomly selected to test the scale reproducibility. -Measurements for to test the hypothesis: a) Face validity: development of a draft questionnaire based on a theoretical model, by using Delphi-type methodology with experts. b) Scale psychometric properties: intraobservers will evaluate video recorded interviews: content-scalability validity (Exploratory Factor Analysis), internal consistency (Cronbach alpha), intra-/inter-observer reliability (Kappa index, intraclass correlation coefficient, Bland & Altman methodology), generalizability, construct validity and sensitivity to change (Pearson product–moment correlation coefficient).
The verification of the hypothesis that EVEM is a valid and reliable tool for assessing motivational interviewing would be a major breakthrough in the current theoretical and practical knowledge, as it could be used to assess if the providers put into practice a patient centered communication style and can be used both for training or researching purposes.
Trials registration Dislip-EM study
Motivational interviewing; Behavior change counseling; Lifestyle change); Dyslipidemia; Cardiovascular risk factors
In an attempt to control chronic benzodiazepine use and its costs in the Netherlands, health care insurance reimbursement of this medication was stopped on January 1st 2009. This study investigates whether benzodiazepine prescriptions issued by general practitioners changed during the first two years following implementation of this regulation.
Registry study based on data from all benzodiazepine users derived from the Registration Network Groningen. This general practice-based research network collects longitudinal data on the primary care administered to about 30,000 patients. Based on the number of quarterly accumulated prescription days, a comparison was made of benzodiazepine prescriptions issued between 2007/2008 and 2009/2010. Also investigated was which type of user (i.e. short-term or long-term) showed the most change.
Information on benzodiazepine prescriptions among 5,200 patients from 16 consecutive trimesters between 2007 and 2010 was available for analysis. A significant reduction in prescription days was observed between 2007/2008 and 2009/2010. Overall, an estimated 1.73 (CI:-1.94 to -1.53; p<0.001) days were less prescribed per trimester after the termination of reimbursement. In particular, short-term users experienced a reduction in prescription days in 2009 and 2010. The number of long-term users decreased by 2.3%, while the number of individuals that did not use increased by 4.2%.
A total reduction of almost 14 prescription days was observed over eight trimesters after implementation of the regulation to terminate the reimbursement of benzodiazepines. Short-term users were mainly responsible for this reduction in prescription days in 2009 and 2010. Although long-term users did not alter their benzodiazepine use in 2009 and 2010, the number of long-term users decreased slightly.
Even though there is convincing evidence that self-care, such as regular exercise and/or stopping smoking, alters the outcomes after an event of coronary heart disease (CHD), risk factors remain. Outcomes can improve if core components of secondary prevention programmes are structurally and pedagogically applied using adult learning principles e.g. problem-based learning (PBL). Until now, most education programs for patients with CHD have not been based on such principles. The basic aim is to discover whether PBL provided in primary health care (PHC) has long-term effects on empowerment and self-care after an event of CHD.
A randomised controlled study is planned for patients with CHD. The primary outcome is empowerment to reach self-care goals. Data collection will be performed at baseline at hospital and after one, three and five years in PHC using quantitative and qualitative methodologies involving questionnaires, medical assessments, interviews, diaries and observations. Randomisation of 165 patients will take place when they are stable in their cardiac condition and have optimised cardiac medication that has not substantially changed during the last month. All patients will receive conventional care from their general practitioner and other care providers. The intervention consists of a patient education program in PHC by trained district nurses (tutors) who will apply PBL to groups of 6–9 patients meeting on 13 occasions for two hours over one year. Patients in the control group will not attend a PBL group but will receive home-sent patient information on 11 occasions during the year.
We expect that the 1-year PBL-patient education will improve patients’ beliefs, self-efficacy and empowerment to achieve self-care goals significantly more than one year of standardised home-sent patient information. The assumption is that PBL will reduce cardiovascular events in the long-term and will also be cost-effective compared to controls. Further, the knowledge obtained from this study may contribute to improving patients’ ability to handle self-care, and furthermore, may reduce the number of patients having subsequent CHD events in Sweden.
A significant number of Canadian rural communities offer local maternity services in the absence of caesarean section back-up to parturient residents. These communities are witnessing a high outflow of women leaving to give birth in larger centres to ensure immediate access to the procedure. A minority of women choose to stay in their home communities to give birth in the absence of such access. In this instance, decision-making criteria and conceptions of risk between physicians and parturient women may not align due to the privileging of different risk factors.
In-depth qualitative interviews and focus groups with 27 care providers and 43 women from 3 rural communities in B.C.
When birth was planned locally, physicians expressed an awareness and acceptance of the clinical risk incurred. Likewise, when birth was planned outside the local community, most parturient women expressed an awareness and acceptance of the social risk incurred due to leaving the community.
The tensions created by these contrasting approaches relate to underlying values and beliefs. As such, an awareness can address the impasse and work to provide a resolution to the competing prioritizations of risk.
Access to care; Rural and remote; Maternity care; Canada; Risk perception
The objective of this study is to perform an independent evaluation of the feasibility and effectiveness of an educational programme for the primary prevention of type 2 diabetes (DM2) in high risk populations in primary care settings, implanted within the Basque Health Service - Osakidetza.
This is a prospective phase IV cluster clinical trial conducted under routine conditions in 14 primary health care centres of Osakidetza, randomly assigned to an intervention or control group. We will recruit a total sample of 1089 individuals, aged between 45 and 70 years old, without diabetes but at high risk of developing the condition (Finnish Diabetes Risk Score, FINDRISC ≥ 14) and follow them up for 2 years. Primary health care nursing teams of the intervention centres will implement DE-PLAN, a structured educational intervention program focused on changing healthy lifestyles (diet and physical activity); while the patients in the control centres will receive the usual care for the prevention and treatment of DM2 currently provided in Osakidetza. The effectiveness attributable to the programme will be assessed by comparing the changes observed in patients exposed to the intervention and those in the control group, with respect to the risk of developing DM2 and lifestyle habits. In terms of feasibility, we will assess indicators of population coverage and programme implementation.
The aim of this study is to provide the scientific basis for disseminate the programme to the remaining primary health centres in Osakidetza, as a novel way of addressing prevention of DM2. The study design will enable us to gather information on the effectiveness of the intervention as well as the feasibility of implementing it in routine practice.
Pre-diabetes; Primary health care; Prevention; Clinical trial