As primary care practices evolve into medical homes, there is an increasing need for effective models to shift from visit-based to population-based strategies for care. However, most medical teams lack tools and training to manage panels of patients. As part of a study comparing different approaches to panel management at the Manhattan and Brooklyn campuses of the VA New York Harbor Healthcare System, we created a toolkit of strategies that non-clinician panel management assistants (PMAs) can use to enhance panel-wide outcomes in smoking cessation and hypertension.
We created the toolkit using: 1) literature review and consultation with outside experts, 2) key informant interviews with staff identified using snowball sampling, 3) pilot testing for feasibility and acceptability, and 4) further revision based on a survey of primary care providers and nurses. These steps resulted in progressively refined strategies for the PMAs to support the primary care team.
Literature review and expert consultation resulted in an extensive list of potentially useful strategies. Key informant interviews and staff surveys identified several areas of need for assistance, including help to manage the most challenging patients, providing care outside of the visit, connecting patients with existing resources, and providing additional patient education. The strategies identified were then grouped into 5 areas – continuous connection to care, education and connection to clinical resources, targeted behavior change counseling, adherence support, and patients with special needs.
Although panel management is a central aspect of patient-centered medical homes, providers and health care systems have little guidance or evidence as to how teams should accomplish this objective. We created a toolkit to help PMAs support the clinical care team for patients with hypertension or tobacco use. This toolkit development process could readily be adapted to other behaviors or conditions.
Panel management; Prevention; Primary care; Hypertension; Smoking cessation
Cases of emerging infectious diseases, including H5N1 influenza, H7N9 influenza, and Middle East Respiratory Syndrome, have been reported in recent years, and the threat of pandemic outbreaks persists. In Japan, primary care is the frontline against emerging infectious diseases in communities. Although the importance of pandemic preparedness in primary care has been highlighted previously, few studies have thus far investigated the preparedness among primary care practices (PCPs) or differences in the preparedness of different institutional settings. We examined PCP preparedness and response to the 2009 influenza pandemic in Japan, and explored the role of a pandemic preparedness plan during the pandemic.
We used a survey questionnaire to assess how well individual PCPs in Okinawa, Japan, were prepared for the 2009 influenza pandemic. The questionnaire was mailed to all eligible PCPs (N = 465) in Okinawa, regardless of their institutional setting. In addition, we assessed the differences in the preparedness of clinics and hospitals and determined whether the national preparedness plan affected individual preparedness and response. Data were analyzed using descriptive and logistic regression analyses.
A total of 174 (37.4%) PCPs responded to our survey. In general, high-level personal protective equipment (PPE) such as N95 masks (45.4%), gowns (30.5%), and eye protection (21.3%) was stocked at a low rate. Clinic-based PCPs were significantly less prepared than hospital-based PCPs to provide N95 masks (OR 0.34), gowns (OR 0.15), and eye protection (OR 0.18). In addition, only 32.8% of PCPs adopted an adequate business continuity plan (BCP). After controlling for institutional setting, reading the national preparedness plan was significantly associated with establishment of a BCP (OR 5.86), and with knowledge of how to transfer a swab specimen to a local medical laboratory (OR 5.60).
With regard to PPE availability, PCPs (especially clinic-based PCPs) were not adequately prepared for the influenza pandemic. Awareness of the national pandemic preparedness plan is likely to promote prefecture-wide implementation of BCPs and surveillance activity.
Primary care practice; Primary care; Preparedness; Response; Pandemic preparedness plan; Personal protective equipment; Business continuity plan; Pandemic influenza
Gout is estimated to affect 1.4% of adults in the UK. Appropriate and timely management is essential to reduce the risk of further flares, complications, and to reduce cardiovascular disease risk. The British Society for Rheumatology and British Health Professionals in Rheumatology (BSR/BHPR) and the European League Against Rheumatism (EULAR) have published guidance regarding the management of gout, thereby providing standards against which performance can be measured. This audit was designed to assess the extent to which patients diagnosed with gout in one primary care medical practice in North Staffordshire, UK, are managed in accordance with current best practice guidelines, and to identify strategies for improvement where appropriate.
Audit criteria were derived from the EULAR and BSR/BHPR guidelines; standards were set arbitrarily, but with consideration of patient comorbidity and other factors which may influence concordance. An electronic search of the practice records was performed to identify adults with a diagnosis of gout. Medical record review with a descriptive analysis was undertaken to assess the extent to which medical management adhered to the predefined standards.
Of the total ≥18 year-old practice population (n = 8686), 305 (3%) patient records included a diagnosis of gout. Of these, 74% (n = 226) had an electronic record of serum uric acid (SUA), and 11% (n = 34) and 53% (n = 162) a measure of estimated glomerular filtration rate (eGFR) ever and serum glucose since diagnosis respectively. 34% (n = 105) of patients had ever taken urate-lowering therapy with 25% (n = 77) currently prescribed this at the time of data extraction. Dose adjustment and monitoring of treatment according to SUA was found to be inadequate. Provision of lifestyle advice and consideration of comorbidities was also lacking.
The primary care management of gout in this practice was not concordant with national and international guidance, a finding consistent with previous studies. This demonstrates that the provision of guidelines alone is not sufficient to improve the quality of gout management and we identify possible strategies to increase guideline adherence.
Gout; Management; Audit; Primary care; Allopurinol; Serum uric acid
Nurses in Denmark have been increasingly involved in general practice care, which may have implications for the role of the general practitioner (GP) and patients’ experience of primary care. The aim of this study was to explore possibilities of doctor-nurse substitution seen from GP and patient perspectives and patient preferences in regard to consultations with a personal GP.
The study was based on data from a Danish survey on disease patterns in general practice (KOS 2008). Background information on patients and GPs was linked with their responses to whether a nurse could have substituted the GP in consultations and patient-assessed importance of seeing a personal GP. Associations were measured with prevalence rate ratio (PR).
Doctor-nurse substitution was a possibility in 14.8% of consultations according to GPs and in 11.7% according to patients. GP and patient agreed on substitution in 3.5% of consultations (Kappa = 0.164). Follow-up consultations were more often feasible for substitution than new episode according to GPs (adj. PR = 2.06 (1.62-2.62)), but not according to patients (adj. PR = 1.02 (0.64-1.33)). Follow-up consultations were related to high importance of seeing the personal GP (adj. PR = 1.18 (1.05-1.33). For both patients and GPs, consultations with patients with chronic conditions were not significantly associated with nurse substitution. Male and younger patients did more often suggest substitution than women and older patients. For GPs, increasing patient age was associated with relevance of substitution. Patients who found it 'very important’ to see their personal GP were less likely to consider nurse substitution a possibility (adj. PR = 0.57 (0.45-0.71).
GPs and patients found nurse substitution relevant in more than one in ten consultations, although they rarely agreed on which consultations. Follow-up consultations and consultations with older patients were associated with GPs considering nurse substitution appropriate more often. For patients, male and younger patients most often found substitution relevant. High importance of seeing the personal GP may contribute to patient reluctance to nurse substitution, especially for follow-up consultations. The results indicate a need for involving patients’ perspective when altering the future roles of primary health care professionals.
Denmark; General practice; Doctor-nurse substitution; Patients’ perspective; Chronic conditions; Follow-up consultations; Health service delivery; Patient-doctor-relationship
ACCEPt, a large cluster randomized control trial, aims to determine if annual testing for 16 to 29 year olds in general practice can reduce chlamydia prevalence. ACCEPt is the first trial investigating the potential role of practice nurses (PN) in chlamydia testing. To inform the design of the ACCEPt intervention, we aimed to determine the chlamydia knowledge, attitudes, and testing practices of participating general practitioners (GPs) and PNs.
GPs and PNs from 143 clinics recruited from 52 areas in 4 Australian states were asked to complete a survey at time of recruitment. Responses of PNs and GPs were compared using conditional logistic regression to account for possible intra cluster correlation within clinics.
Of the PNs and GPs enrolled in ACCEPt, 81% and 72% completed the questionnaire respectively. Less than a third of PNs (23%) and GPs (32%) correctly identified the two age groups with highest infection rates in women and only 16% vs 17% the correct age groups in men. More PNs than GPs would offer testing opportunistically to asymptomatic patients aged ≤25 years; women having a pap smear (84% vs 55%, P<0.01); antenatal checkup (83% vs 44%, P<0.01) and Aboriginal men with a sore throat (79% vs 33%, P<0.01), but also to patients outside of the guideline age group at the time of the survey; 26 year old males presenting for a medical check (78% vs 30%, P = <0.01) and 33 year old females presenting for a pill prescription (83% vs 55%, P<0.01). More PNs than GPs knew that retesting was recommended after chlamydia treatment (93% vs 87%, P=0.027); and the recommended timeframe was 3 months (66% vs 26%, P<0.01). A high proportion of PNs (90%) agreed that they could conduct chlamydia testing in general practice, with 79% wanting greater involvement and 89% further training.
Our survey reveals gaps in chlamydia knowledge and management among GPs and PNs that may be contributing to low testing rates in general practice. The ACCEPt intervention is well targeted to address these and support clinicians in increasing testing rates. PNs could have a role in increasing chlamydia testing.
The process of initiating and maintaining healthy lifestyle behaviours is complex, includes a number of distinct phases and is not static. Theoretical models of behaviour change consider psychological constructs such as intention and self efficacy but do not clearly consider the role of stress or psychological distress. General practice based interventions addressing lifestyle behaviours have been demonstrated to be feasible and effective however it is not clear whether general practitioners (GPs) take psychological health into consideration when discussing lifestyle behaviours. This qualitative study explores GPs’ and patients’ perspectives about the relationship between external stressors, psychological distress and maintaining healthy lifestyle behaviours.
Semi-structured telephone interviews were conducted with 16 patients and 5 GPs. Transcripts from the interviews were thematically analysed and a conceptual model developed to explain the relationship between external stressors, psychological distress and healthly lifestyle behaviours.
Participants were motivated to maintain a healthy lifestyle however they described a range of external factors that impacted on behaviour in both positive and negative ways, either directly or via their impact on psychological distress. The impact of external factors was moderated by coping strategies, beliefs, habits and social support. In some cases the process of changing or maintaining healthy behaviour also caused distress. The concept of a threshold level of distress was evident in the data with patients and GPs describing a certain level of distress required before it negatively influenced behaviour.
Maintaining healthy lifestyle behaviours is complex and constantly under challenge from external stressors. Practitioners can assist patients with maintaining healthy behaviour by providing targeted support to moderate the impact of external stressors.
Studies have shown a correlation between gender and an ability to change lifestyle to reduce the risk of disease. However, the results of these studies are ambiguous, especially where a healthy lifestyle is concerned. Additionally, health behaviors are strongly modified by culture and the environment. Psychological factors also substantially affect engagement with disease-related lifestyle interventions. This study aimed to examine whether there are differences between men and women in the frequency of health care behavior for the purpose of reducing cardiovascular risk (CVR), as well as cognitive appraisal of this type of risk. We also aimed to identify the psychological predictors of engaging in recommended behavior for reducing the risk of cardiovascular disease after providing information about this risk in men and women.
A total of 134 consecutive eligible patients in a family practice entered a longitudinal study. At initial consultation, the individual’s CVR and associated health burden was examined, and preventive measures were recommended by the physician. Self-care behavior, cognitive appraisal of risk, and coping styles were then assessed using psychological questionnaires. Six months after the initial data collection, the frequency of subjects’ self-care behavior was examined.
We found an increase in health care behavior after providing information regarding the rate of CVR in both sexes; this increase was greater for women than for men. Women followed self-care guidelines more often than men, particularly for preventive measures and dietary advice. Women were more inclined to recognize their CVR as a challenge. Coping style, cognitive appraisal, age, level of health behaviors at baseline and CVR values accounted for 48% of the variance in adherence to self-care guidelines in women and it was 52% in men. In women, total risk of CVD values were most important, while in men, cognitive appraisal of harm/loss was most important.
Different predictors of acquisition of health behavior are encountered in men and women. Our results suggest that gender-adjusted motivation models influencing the recognition process need to be considered to optimize compliance in patients with CVR.
Adherence; Cardiovascular risk; Coping; Gender; Health behavior; Stress
Frequent attenders receive much attention in primary care research. Defining frequent attendance is crucial for an adequate view on this group of demanding patients. We aimed to develop a purely contact-based definition of “frequent attendance” and to apply it to real patients.
From electronic records of 123 general practices in Germany, patients’ inter-contact intervals (ICI) between two consecutive doctor-patient-contacts were calculated in this retrospective observational study. ICI less than 7 days were labelled “frequent attendance”, patients with 60% or more of such intervals “frequent attenders (new view)”. In contrast, patients having at least 24 contacts per calendar year were considered “frequent attenders (traditional view)”. Both groups were analysed in their diseases and demands, using multiple logistic regression.
A total of 177,057 patients with at least 3 ICI in 1996 until 2006 yielded 4,408,033 ICI. One third were “short” ICI (less than 7 days), resulting in 19,759 (11.2%) frequent attenders (new). In contrast, 22,921 (12.9%) patients were frequent attenders (traditional). Compared to non-frequent attenders, frequent attenders (new) were more likely to have pneumonia (OR 1.66), stroke (OR 1.49), dementia (OR 1.46), or severe substance abuse (OR 1.44), also to need home visits or emergency attention. Frequent attenders (traditional) were more likely to have dementia (OR 2.76) or stroke (OR 2.06), and by far to need home visits (OR 5.43; all p < 0.001).
A new measure, the interval in days of two consecutive face-to-face contacts (ICI), widens our perspective on frequent attenders in general practice. In many cases, their consultation behaviour and need for medical services seem to follow “disease logic”.
General practice; Office visits; Physician-patient relations; Appointment and schedules; Workload
The Egyptian government is considering embarking on a new wave of health sector reform. Although primary care is seen as central to the anticipated reforms, little is known about the current morbidity and utilization patterns in Egyptian publicly funded primary care. We conducted this survey study of patient encounters to describe the demographic characteristics of patients attending publicly-funded primary care practices, the relative frequency of conditions encountered in these practices, and the rates of drug prescription, investigation and referral.
Cross-sectional survey of twelve primary care practices and 2458 patient consultations. Additional secondary data were collected from five of the twelve practices for preventive services provided at these practices i.e. immunizations, family planning and ante-natal care.
54% of the attendances were for people below the age of twenty, of which 54% were females. In patients above the age of twenty, women accounted for 73% of consultations. Upper respiratory tract infection was the most common reason for encounter, accounting for 24% of the presentations, followed by gastroenteritis (10%), intestinal parasites (5%), and lower respiratory tract infections (5%). Over 97% of patients were prescribed at least one drug, whereas investigation and referral rates were low (15% and 5% respectively). When the analysis was repeated for practices where data on both curative and preventive services were available (5 practices and 2146 consultations), substantial proportions of patients were found to seek care for immunizations (25%), family planning (12%), and ante-natal care (11%).
Most patients utilizing primary care practices in Egypt seek care for minor and preventive services with relatively few consultations for more serious conditions. There is also a pattern of prescribing drugs to most primary care patients which may reflect over-prescribing by primary care doctors.
Family practice; Primary health care; Egypt; Morbidity; Epidemiology; Demography; Physician’s practice patterns; Health care surveys; Health services research; Health facility administration
The General Practice Assessment Questionnaire (GPAQ) has been widely used to assess patient experience in general practice in the UK since 2004. In 2013, new regulations were introduced by the General Medical Council (GMC) requiring UK doctors to undertake periodic revalidation, which includes assessment of patient experience for individual doctors. We describe the development of a new version of GPAQ – GPAQ-R which addresses the GMC’s requirements for revalidation as well as additional NHS requirements for surveys that GPs may need to carry out in their own practices.
Questionnaires were given out by doctors or practice staff after routine consultations in line with the guidance given by the General Medical Council for surveys to be used for revalidation. Data analysis and practice reports were provided independently.
Data were analysed for questionnaires from 7258 patients relating to 164 GPs in 29 general practices. Levels of missing data were generally low (typically 4.5-6%). The number of returned questionnaires required to achieve reliability of 0.7 were around 35 for individual doctor communication items and 29 for a composite score based on doctor communication items. This suggests that the responses to GPAQ-R had similar reliability to the GMC’s own questionnaire and we recommend 30 completed GPAQ-R questionnaires are sufficient for revalidation purposes. However, where an initial screen raises concern, the survey might be repeated with 50 completed questionnaires in order to increase reliability.
GPAQ-R is a development of a well-established patient experience questionnaire used in general practice in the UK since 2004. This new version can be recommended for use in order to meet the UK General Medical Council’s requirements for surveys to be used in revalidation of doctors. It also meets the needs of GPs to ask about patient experience relating to aspects of practice care that are not specific to individual general practitioners (e.g. receptionists, telephone access) which meet other survey requirements of the National Health Service in England. Use of GPAQ-R has the potential to reduce the number of surveys that GPs need to carry out in their practices to meet the various regulatory requirements which they face.
Psoriasis is a chronic, inflammatory skin disease affecting approximately 2% of the UK population and is currently incurable. It produces profound effects on psychological wellbeing and social functioning and has significant associated co-morbidities. The majority of patients with psoriasis are managed in primary care, however in-depth patient and GP perspectives about psoriasis management in this setting are absent from the literature. This article reports an in-depth study which compares and contrasts the perspectives of people with psoriasis and of GPs on the challenges of managing psoriasis in primary care.
In-depth, qualitative semi-structured interviews were conducted with a diverse sample of 29 people with psoriasis and 14 GPs. Interviews were coded using principles of Framework Analysis to enable a comparison of patient and practitioner perspectives on key issues and concepts arising from the data.
Patients perceived GPs to be lacking in confidence in the assessment and management of psoriasis and both groups felt lacking in knowledge and understanding about the condition. While practitioners recognised that psoriasis has physical, emotional and social impact, they assumed patients had expertise in the condition and may not address these issues in consultations. This resulted in patient dissatisfaction and sub-optimal assessment of severity and impact of psoriasis by GPs. Patients and GPs recognised that psoriasis was not being managed as a complex long-term condition, however this appeared less problematic for GPs than for patients who desired a shared management with their GP incorporating appropriate monitoring and timely reviews.
The research suggests that current routine practice for psoriasis management in primary care is mismatched with the expressed needs of patients. To address these needs, psoriasis must be recognised as a complex long-term condition involving exacting physical, psychological and social demands, co-morbidity and the development of new treatments.
General practitioners need to improve both their knowledge and skills in the assessment and management of psoriasis. This in turn will facilitate management of the condition in partnership with patients. Commissioning multi-disciplinary services, which focus on long-term impacts on wellbeing and quality of life, might address current deficits in care.
Psoriasis; Qualitative research; Primary health care; Patient perspectives; Self-care; General practitioners; NICE guidelines
Cigarette smoking remains the leading preventable cause of death and disease. Thus, all activities aiming to reduce smoking play an important role in improving population health. The positive role of the general practitioner (GP) in smoking cessation could increase the success rate for quitting smoking, if compared with unassisted cessation. The aim of this study was to determine what kind of general practitioner smokers need in order to stop smoking.
Four focus groups with 12 current and 12 former smokers (aged 20-59, 11 women and 13 men), were arranged in the city of Toruń, Poland, with a view to describe their opinions on the GP’s role in smoking cessation. The data were subjected to descriptive qualitative content analysis.
Two major themes emerged in the analysis: the smokers’ positive and negative experiences of the GP in smoking cessation and their expectations regarding the role of the GP in smoking cessation. The first theme embraced the following subthemes: (1) GP’s passivity, (2) routine questions about the patient’s smoking during the visit, (3) lack of time during the visit, and (4) the role model of the GP in smoking cessation. Within the second theme, the respondents identified the following subthemes: (1) bringing up the topic of smoking cessation, even in situations when the patient is unprepared for this; (2) the necessity of a tailored approach to the patient; (3) access to information and evidence confirming the harms of smoking tobacco; (4) prescription of pharmacological and other treatment; and (5) referral to specialists in smoking cessation.
Patients expect their GP to actively participate in smoking cessation through a more tailored approach to the patient’s needs. The patients’ experiences did not match their expectations: the smokers rarely got advice on smoking cessation from their GPs. Finally, they emphasized the importance of the GP as a role model in smoking cessation.
Smoking cessation; Primary care; Qualitative research
Primary care-based care management (CM) could reduce hospital admissions in high-risk patients. Identification of patients most likely to benefit is needed as resources for CM are limited. This study aimed to compare hospitalization and mortality rates of patients identified for CM either by treating primary care physicians (PCPs) or predictive modelling software for hospitalization risk (PM).
In 2009, a cohort of 6,026 beneficiaries of a German statutory health insurance served as a sample for patient identification for CM by PCPs or commercial PM (CSSG 0.8, Verisk Health). The resulting samples were compared regarding hospitalization and mortality rates in 2010 and in the two year period before patient selection. No CM-intervention was delivered until the end of 2010 and PCPs were blinded for the assessment of hospitalization rates.
In 2010, hospitalization rates of PM-identified patients were 80% higher compared to PCP-identified patients. Mortality rates were also 8% higher in PM-identified patients if compared to PCP-identified patients (10% vs. 2%). The hospitalization rate of patients independently identified by both PM and PCPs was numerically between PM- and PCP-identified patients. Time trend between 2007 and 2010 showed decreasing hospitalization rates in PM-identified patients (−15% per year) compared to increasing rates in PCP-identified patients (+34% per year).
PM identified patients with higher hospitalization and mortality rates compared to PCP-referred patients. But the latter showed increasing hospitalization rates over time thereby suggesting that PCPs may be able to predict future deterioration in patients with relatively good current health status. These patients may most likely benefit from preventive services like CM.
Decision support techniques; Case finding; Case management; Disease management; Primary care; Multimorbidity; Avoidable hospitalization; Prediction
Obesity, a threatening pandemic, has an important public health implication. Before proper medication is available, primary care providers will have a distinguished role in prevention and management. Their performance may be influenced by many factors but their personal motivation is still an under-researched area.
The knowledge, attitudes and practice were reviewed in this questionnaire study involving a representative sample of 10% of all Hungarian family physicians. In different settings, 521 practitioners (448 GPs and 73 residents/vocational trainees) were questioned using a validated questionnaire.
The knowledge about multimorbidity, a main consequence of obesity was balanced.
Only 51% of the GPs were aware of the diagnostic threshold for obesity; awareness being higher in cities (60%) and the highest among residents (90%). They also considered obesity an illness rather than an aesthetic issue.
There were wider differences regarding attitudes and practice, influenced by the the doctors’ age, gender, known BMI, previous qualification, less by working location.
GPs with qualification in family medicine alone considered obesity management as higher professional satisfaction, compared to physicians who had previously other board qualification (77% vs 68%). They measured their patients’ waist circumference and waist/hip ratio (72% vs 62%) more frequently, provided the obese with dietary advice more often, while this service was less frequent among capital-based doctors who accepted the self-reported body weight dates by patients more commonly. Similar reduced activity and weight-measurement in outdoor clothing were more typical among older doctors.
Diagnosis based on BMI alone was the highest in cities (85%). Consultations were significantly shorter in practices with a higher number of enrolled patients and were longer by female providers who consulted longer with patients about the suspected causes of developing obesity (65% vs 44%) and offered dietary records for patients significantly more frequently (65% vs 52%). Most of the younger doctors agreed that obesity management was a primary care issue.
Doctors in the normal BMI range were unanimous that they should be a model for their patients (94% vs 81%).
More education of primary care physicians, available practical guidelines and higher community involvement are needed to improve the obesity management in Hungary.
Attitudes; Family physician; General practitioner; Hungarian; Knowledge; Management; Obesity; Overweight; Practice; Survey
Chest pain is a common complaint and reason for consultation in primary care. Traditional textbooks still assign pain localization a certain discriminative role in the differential diagnosis of chest pain. The aim of our study was to synthesize pain drawings from a large sample of chest pain patients and to examine whether pain localizations differ for different underlying etiologies.
We conducted a cross-sectional study including 1212 consecutive patients with chest pain recruited in 74 primary care offices in Germany. Primary care providers (PCPs) marked pain localization and radiation of each patient on a pictogram. After 6 months, an independent interdisciplinary reference panel reviewed clinical data of every patient, deciding on the etiology of chest pain at the time of patient recruitment. PCP drawings were entered in a specially designed computer program to produce merged pain charts for different etiologies. Dissimilarities between individual pain localizations and differences on the level of diagnostic groups were analyzed using the Hausdorff distance and the C-index.
Pain location in patients with coronary heart disease (CHD) did not differ from the combined group of all other patients, including patients with chest wall syndrome (CWS), gastro-esophageal reflux disease (GERD) or psychogenic chest pain. There was also no difference in chest pain location between male and female CHD patients.
Pain localization is not helpful in discriminating CHD from other common chest pain etiologies.
Chest pain; Pain localization; Coronary heart disease
Within the health system, communication between the different levels of care is essential for the patients’ clinical pathways and medical treatment. This includes the referral process: how and why patients are sent from the primary care level to specialist health services. We wanted to identify and describe hospital consultants’ reflections on and attitudes to the referral process and cooperation with general practitioners (GPs).
A qualitative study of semi-structured interviews with 13 hospital consultants representing eight different specialties, analyzed using systematic text condensation. Interviews conducted from February 2011 to October 2012.
The consultants reported a considerable workload assessing referrals from GPs and prioritizing patients for specialist services. National guidelines were used as well as individual standards and guidelines. Good referrals could make the prioritization process easier. The specialists expressed a deep concern about securing a fair priority of patients and a willingness to give reasonable advice back to the referring GP when rejecting a referral. Better communication, such as a telephone call to confer with a hospital specialist before referral, was wanted.
Better communication and cooperation between hospital consultants and GPs could make the referral process more balanced, and the participants more like partners.
Care for overweight children in general practice involves collaboration with parents. Acknowledging the parents’ frames of references is a prerequisite for successful management. We therefore aimed to analyse parental beliefs about the presumed causes and consequences of overweight in children and expectations towards the GP. Moreover, we aimed at comparing the beliefs and expectations of parents of non-overweight children (NOWC) and parents of overweight children (OWC).
A cross-sectional survey. Data were obtained from a questionnaire exploring parents’ beliefs and expectations regarding overweight in children. The questionnaires were completed by parents following their child’s participation in the five-year preventive child health examination (PCHE).
Parental agreement upon statements concerning beliefs and expectations regarding overweight in children was measured on a Likert scale. Differences in levels of agreement between parents of non-overweight children and parents of overweight children were analysed using Chi-squared test and Fisher’s exact test.
Parents of 879 children completed and returned questionnaires. Around three fourths of the parents agreed that overweight was a health problem. A majority of parents (93%) agreed that the GP should call attention to overweight in children and offer counselling on diet and exercise. Almost half of the parents expected a follow-up programme. Parents of overweight children seemed to agree less upon some of the proposed causes of overweight, e.g. inappropriate diet and lack of exercise. These parents also had stronger beliefs about overweight disappearing by itself as the child grows up.
According to parental beliefs and expectations, general practice should have an important role to play in the management of child overweight. Moreover, our findings suggest that GPs should be aware of the particular beliefs that parents of overweight children may have regarding causes of overweight in their child.
Children; Overweight; Parents; Beliefs; Expectations; General practice
Data on the prevalence of depression and on how a depressive episode prompts the sufferer to seek primary care are not scarce, but the available evidence on the prevalence of depression among immigrants and poor people who frequent general practice facilities is scarce. The Baudelaire Outpatient Clinic at the Saint-Antoine Hospital in Paris provides free medical and social assistance to the poor and/or uninsured. The goal of our study was to estimate the prevalence of depression among these outpatients, to characterize this depressed population, and to analyze its demand for primary care for depressive episodes.
From September to December 2010, we conducted a cross-sectional, observational survey among users of the Baudelaire Outpatient Clinic. French-speaking patients attending the clinic between September 15 and December 30, 2010 who agreed to answer a questionnaire administered face-to-face before their consultation were included in the study. The chi-squared test (or Fisher’s exact test for small samples) was used for the comparisons of proportions. Logistic regression models were estimated, along with the odds ratios (OR) and their 95% confidence intervals (95% CIs), for the multivariate analysis of factors associated with depression and healthcare-seeking. Models were estimated separately for men and women, since sex was an interaction factor. The statistical analyses were performed using Stata v. 10 software (StataCorp LP, College Station, Texas, USA).
Of the 250 patients included (mean age: 45 years), 52.0% were men and 52.4% were immigrants. Close to 40% of them reported having no supplemental health insurance. The estimated prevalence of depression in this population was 56.7%. Depression was more prevalent among the women, immigrants, and people from the poorer socioeconomic groups. Only half of these depressed patients, mostly women, reported having discussed their depression with a physician. French nationality and complete health insurance coverage were associated with more-frequent healthcare-seeking. Few patients reported having been asked about their morale by the physician they consulted, and almost 80% would have liked to be asked about this more often.
Depression is a real public health problem, particularly among people from disadvantaged backgrounds, and should be included in their overall management.
Depression; Primary care; Seeking healthcare; Homeless; Immigrants; Paris; France
Patients with rheumatoid arthritis (RA) are known to be at increased risk of vascular disease. It is not known whether screening for vascular risk factors occurs in primary care. The aim of this study was to determine whether guidance advocating cardiovascular screening in RA patients is being implemented in primary care.
This study was undertaken in a UK primary care consultation database. All patients with a diagnosis of RA between 2000 and 2008, and still registered with the GP practice in 2009 were matched by age, gender and GP practice to three non-RA patients. Evidence of screening for five traditional vascular risk factors (blood pressure, lipids, glucose, weight, smoking) was compared in those with and without RA using logistic regression models. A comparison was also made with diabetes.
401 RA patients were identified and matched to 1198 non-RA patients. No differences in the overall rates of screening were found (all five risk factors: RA 24.9% vs no RA 25.6%), but RA patients were more likely to have a smoking status recorded (67% versus 62%). In contrast, those with diabetes were up to 12 times as likely to receive vascular screening.
Despite the excess risk of vascular disease in patients with RA being of a similar magnitude to that seen in diabetes, patients with RA did not receive additional CVD screening in primary care, although this was achieved in patients with diabetes. More emphasis needs to be placed on ensuring those with RA are actively screened for cardiovascular disease in primary care.
The current research into single nucleotide polymorphisms has extended the role of genetic testing to the identification of increased risk for common medical conditions. Advances in genetic research may soon necessitate preparation for the role of genetic testing in primary care medicine. This study attempts to determine what proportion of patients would be willing to undergo genetic testing for salt-sensitive hypertension in a primary care setting, and what factors are related to this willingness.
A cross-sectional study using a self-report questionnaire was conducted among outpatients in primary care clinics and hospitals in Japan. The main characteristics measured were education level, family medical history, personal medical history, concern about hypertension, salt preference, reducing salt intake, and willingness to undergo genetic testing for salt-sensitive hypertension.
Of 1,932 potential participants, 1,457 (75%) responded to the survey. Of the respondents, 726 (50%) indicated a willingness to undergo genetic testing. Factors related to this willingness were being over 50 years old (adjusted odds ratio [ad-OR] = 1.42, 95% Confidence interval = 1.09 – 1.85), having a high level of education (ad-OR: 1.83, 1.38 – 2.42), having a family history of hypertension (ad-OR: 1.36, 1.09 – 1.71), and worrying about hypertension (ad-OR: 2.06, 1.59 – 2.68).
Half of the primary care outpatients surveyed in this study wanted to know their genetic risk for salt-sensitive hypertension. Those who were worried about hypertension or had a family history of hypertension were more likely to be interested in getting tested. These findings suggest that primary care physicians should provide patients with advice on genetic testing, as well as address their anxieties and concerns related to developing hypertension.
Attitudes; Genetic testing; Salt-sensitive hypertension; Primary care; Outpatient
There are several guidelines dealing with the management of low back pain (LBP), but only few studies on the quality of care provided within General Practices as judged against those guidelines.
The objective of this study is to analyse the management of LBP in Italian General Practice and compare it with guideline recommendations.
In this observational study, all patients visiting their General Practitioners (GPs) for treatment of LBP within a 8-week period were monitored for at least four weeks with regard to symptoms and diagnostic and therapeutic interventions. Management of LBP was judged by pre-defined quality indicators based on guideline recommendations.
Twenty-five of 114 eligible GPs participated in the study, representing a total of 43,012 registered patients. Of the 475 patients complaining of LBP and monitored for four weeks, 55.8% were diagnosed as having acute lumbar pain, 13.5% chronic lumbar pain, 17.1% acute sciatica, and 12.6% chronic sciatica; 76.0% underwent no technical investigations, 21.7% underwent x-rays, 5.5% MRI and 4% CT scans; 20.4% were referred to secondary care; 93.3% of all patients received some medication. In those receiving a medication, in 88.3% it was an NSAID, in 6.3% Paracetamol, in 10.4% Paracetamol combined with Codeine, and in 9% a muscle relaxants. When physiotherapy was prescribed (17,1%), it was mostly massage. Hardly more than 50% of GPs (partially) followed locally established guidelines, while the remainder seemed not to follow guidelines at all.
Our study reveals gross deviations of GP management of LBP from current guidelines and points to two different types of deviators: those who partially follow guidelines, and those who do not follow them at all. Further research should evaluate whether these two types of deviation are best addressed by different foci of education, i.e. on knowledge versus attitudes, respectively.
Low back pain; General practice; Guideline adherence; Diagnostic imaging
People living with chronic disease currently account for the majority of the total healthcare costs. The Central Denmark Region implemented a disease management programme (DMP) for chronic obstructive pulmonary disease (COPD) in 2008. This presented an opportunity to examine the effect of an evidence-based, planned and proactive implementation of a DMP compared to the usual implementation strategy.
We performed a block- and cluster-randomised controlled trial with two groups and an extra external control group. The primary outcome was patients’ assessment of their care after using an active implementation model for a DMP for COPD measured with the Patient-Assessment-of-Chronic-Illness-Care (PACIC) instrument. At baseline, questionnaires were sent to 2,895 patients identified by an algorithm based on health registry data on lung-related contacts to the healthcare system. Patients were asked to confirm or refute their diagnosis of COPD. Of those who responded, 1,445 (72.8%) confirmed their diagnosis. PACIC data were collected at baseline and at a 12-month follow-up for 744 (51.1%) patients.
Comparing the three groups after the implementation of the DMP, we found a statistically significantly higher change in the PACIC score in the intervention group than in the control groups. No statistically significant differences were found between the control and the external control groups in any of the dimensions.
Reinforcing the role of general practice as coordinator for care-and self-management-support with an active implementation of a DMP for COPD made patients score higher on the PACIC instrument, which indicates a better experience of the received healthcare.
PACIC; Implementation; Disease management programme; Patient evaluation; COPD; Chronic care model; RCT
There has been created an online communication tool with the objective to improve the communication among different levels of care, between Primary Care clinicians and Specialists. This tool is web 2.0 based technology (ECOPIH project). It allows to review clinical cases and to share knowledge. Our study will evaluate its impact in terms of reduction on the number of referrals to three specialties two years after the use of this tool.
Open, multicenter, controlled, non random intervention study over 24 months. Study population includes 131 Primary Care Physicians assigned to nine health centers. The study will compare the clinicians that use the ECOPIH with the ones that do not use the tool. Also, professionals that start to use the tool during the period time of the study will be included.
The number of annual referrals during the first and second year will be analyzed and retrospectively compared with the previous year to the implementation of the tool. Moreover, it will be assessed the level of satisfaction of the professionals with the tool and to what extend the tool responds to their needs.
The implementation of ECOPIH in the field of Primary Health Care can decrease the number of referrals from primary care to specialist care.
It is expected that the reduction will be more noticeable in the group of professionals that use more intensively the tool. Furthermore, we believe that it can be also observed with the professionals that read the contributions of the others.
We anticipate high degree of customer satisfaction as it is a very helpful resource never used before in our environment.
Remote consultation; Primary health care; Problem solving; Telemedicine; Referral and consultation; Education medical continuing
The numbers of learners seeking placements in general practice is rapidly increasing as an ageing workforce impacts on General Practitioner availability. The traditional master apprentice model that involves one-to-one teaching is therefore leading to supervision capacity constraints. Vertically integrated (VI) models may provide a solution. Shared learning, in which multiple levels of learners are taught together in the same session, is one such model. This study explored stakeholders’ perceptions of shared learning in general practices in northern NSW, Australia.
A qualitative research method, involving individual semi-structured interviews with GP supervisors, GP registrars, Prevocational General Practice Placements Program trainees, medical students and practice managers situated in nine teaching practices, was used to investigate perceptions of shared learning practices. A thematic analysis was conducted on 33 transcripts by three researchers.
Participants perceived many benefits to shared learning including improved collegiality, morale, financial rewards, and better sharing of resources, knowledge and experience. Additional benefits included reduced social and professional isolation, and workload. Perceived risks of shared learning included failure to meet the individual needs of all learners. Shared learning models were considered unsuitable when learners need to: receive remediation, address a specific deficit or immediate learning needs, learn communication or procedural skills, be given personalised feedback or be observed by their supervisor during consultations. Learners’ acceptance of shared learning appeared partially dependent on their supervisors’ small group teaching and facilitation skills.
Shared learning models may partly address supervision capacity constraints in general practice, and bring multiple benefits to the teaching environment that are lacking in the one-to-one model. However, the risks need to be managed appropriately, to ensure learning needs are met for all levels of learners. Supervisors also need to consider that one-to-one teaching may be more suitable in some instances. Policy makers, medical educators and GP training providers need to ensure that quality learning outcomes are achieved for all levels of learners. A mixture of one-to-one and shared learning would address the benefits and downsides of each model thereby maximising learners’ learning outcomes and experiences.
Registrars; Prevocational trainees; Medical students; Medical education; Vertical integration; Near-peer teaching; General practice; Postgraduate training
Organisational problems contribute to many errors in healthcare delivery. Our objective was to identify the most important organisational items in primary care which could be targeted by programs to improve patient safety.
A web-based survey was undertaken in an international panel of 65 experts on patient safety from 20 countries. They were asked to rate 52 patient safety items on a five-point Likert scale which regards importance of each item for use for educational interventions to improve patient safety.
The following 7 organizational items were regarded ‘extremely important’ by more than 50% of the experts: the use of sterile equipment with small surgical procedures (63%), the availability of adequate emergency drugs in stock (60%), regular cleaning of facilities (59%), the use of sterile surgical gloves when recommended (57%), the availability of at least one adequately trained staff member to deal with collapse and need for resuscitation (56%), adequate information handover when a patient is discharged from the hospital (56%) and periodically training of GPs in basic life support and other medical emergencies (53%).
Seven organisational items were consistently prioritized; other items may be relevant in specific countries only. The logical next step is to develop and evaluate interventions targeted at these items.
Patient safety; Primary care; Audit; Feedback; Prospective risk analysis