Measuring concentration in primary care

There is evidence that patient choice and the quality of service delivery in primary care can be influenced by the organisation and structure of provision at the local level. However, the formal measurement of structure in primary care has yet to be undertaken. Using data for Coventry, standard concentration measures are estimated, which show that concentration varies considerably across the city and tends to be higher in areas of lower deprivation. Assuming that patient choice is an important consideration in health care planning, concentration measurement may provide a useful tool for health authorities in making decisions about GP numbers, practice mergers and re‐location. This revised version was published online in July 2006 with corrections to the Cover Date.     

Comprehensive cancer screening in a primary care population: Gender differences in the impact of ambulatory care system factors

There is a great deal to be learned about how factors within the context of primary care influence the provision of comprehensive preventive services. This study assessed the prevalence of cancer screening among a primary care population of men and women and examined the association of characteristics of the patient-physician relationship, the healthcare facility, and type of health insurance. Findings suggest that prevalence of comprehensive cancer screening is low, particularly among men. Characteristics of the patient-physician relationship are an important predictor of screening among women but not men. Among men, however, greater contact with the medical care system is important.     

Evaluation of the DINAMAP blood pressure monitor in an ambulatory primary care setting

Automatic blood pressure recorders have gained acceptance in many clinical settings. New devices have usually been validated with invasive monitoring as the "gold standard." There is a lack of sound empirical evidence, however, supporting the routine use of these monitors in ambulatory settings. This study evaluated the DINAMAP 8100, an oscillometric automated blood pressure monitor, using the Hawksley Random-Zero Sphygmomanometer as the standard. A sample of 80 normotensive and hypertensive ambulatory patients from the Department of Family Medicine at the Medical University of South Carolina were studied. A clinical trial was conducted in which readings from the DINAMAP 8100 were compared with those from the Hawksley Random-Zero Sphygmomanometer, in a 2 (instrument) X 2 (arm) X 2 (investigators) X 4 (pairs of simultaneous measurements) factorial design. The DINAMAP 8100 overestimated systolic readings (mean difference = 7.6 +/- 9.1 mmHg, P less than .0001, paired t test). More than one third of systolic measurements and one quarter of diastolic measurements were greater than 10 mmHg discrepant from the standard. The results of this study suggest that routine use of the DINAMAP 8100 would lead to serious misclassification errors in screening for hypertension and in the follow-up of known hypertensive patients. The DINAMAP 8100, therefore, is not an appropriate instrument for routine use in primary care settings.     

Measuring the outcomes of long-term care

How should we measure the value of long-term (social) care? This paper describes a care-related quality of life instrument (ASCOT) and considers aspects of its validity. In particular the aim is to assess whether ASCOT is better suited to measuring the impact of long-term care services than the EQ5D health-related quality of life measure. Long-term care services tend to be more concerned with addressing the day-to-day consequences of long-term conditions. As such, a quality of life measure should not be overly focused on the potential impact of services on personal ability and should instead consider how services directly help people to function in everyday life. Construct validity was judged by assessing the degree to which measured quality of life improvement was consistent with the theorised positive correlation between quality of life and the use of home care services. In a 2008/9 sample of people using care services in England, we found that the impact of service use was significant when measured by ASCOT, but not significant when using EQ5D. The results support our hypothesis that ASCOT has greater construct validity in this case.     

Measuring the outcomes of long-term care

How should we measure the value of long-term (social) care? This paper describes a care-related quality of life instrument (ASCOT) and considers aspects of its validity. In particular the aim is to assess whether ASCOT is better suited to measuring the impact of long-term care services than the EQ5D health-related quality of life measure. Long-term care services tend to be more concerned with addressing the day-to-day consequences of long-term conditions. As such, a quality of life measure should not be overly focused on the potential impact of services on personal ability and should instead consider how services directly help people to function in everyday life. Construct validity was judged by assessing the degree to which measured quality of life improvement was consistent with the theorised positive correlation between quality of life and the use of home care services. In a 2008/9 sample of people using care services in England, we found that the impact of service use was significant when measured by ASCOT, but not significant when using EQ5D. The results support our hypothesis that ASCOT has greater construct validity in this case.     

The role of primary care in preventing ambulatory care sensitive conditions

BACKGROUND: To examine the postulated relationship between Ambulatory Care Sensitive Conditions (ACSC) and Primary Health Care (PHC) in the US context for the European context, in order to develop an ACSC list as markers of PHC effectiveness and to specify which PHC activities are primarily responsible for reducing hospitalization rates. METHODS: To apply the criteria proposed by Solberg and Weissman to obtain a list of codes of ACSC and to consider the PHC intervention according to a panel of experts. Five selection criteria: i) existence of prior studies; ii) hospitalization rate at least 1/10,000 or 'risky health problem'; iii) clarity in definition and coding; iv) potentially avoidable hospitalization through PHC; v) hospitalization necessary when health problem occurs. Fulfilment of all criteria was required for developing the final ACSC list. A sample of 248,050 discharges corresponding to 2,248,976 inhabitants of Catalonia in 1996 provided hospitalization rate data. A Delphi survey was performed with a group of 44 experts reviewing 113 ICD diagnostic codes (International Classification of Diseases, 9th Revision, Clinical Modification), previously considered to be ACSC. RESULTS: The five criteria selected 61 ICD as a core list of ACSC codes and 90 ICD for an expanded list. CONCLUSIONS: A core list of ACSC as markers of PHC effectiveness identifies health conditions amenable to specific aspects of PHC and minimizes the limitations attributable to variations in hospital admission policies. An expanded list should be useful to evaluate global PHC performance and to analyse market responsibility for ACSC by PHC and Specialist Care.     

24-Hour ambulatory blood pressure monitoring in primary care

BACKGROUND: Both the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of Hypertension in Adults and the British Hypertension Society have made recommendations for the use of ambulatory blood pressure monitoring (ABPM) in select patient populations. This demonstration project explores the feasibility of a 24-hour ABPM service in assisting physicians with decisions regarding the implementation and modification of antihypertensive therapy. METHODS: After physician referral, patients met with a pharmacist for evaluation of their blood pressure. The pharmacist obtained a medication profile and instructed each patient on the proper use of the monitor. Patients completed an activity diary while wearing the monitor. After analysis of the reports, the pharmacist forwarded recommendations and the 24-hour blood pressure data to the referring physician. RESULTS: Sixty patients took part in the demonstration project. The primary reasons for referral included evaluation of suspected isolated office hypertension, drug resistance, blood pressure control in diabetic patients, and suspected drug-induced orthostatic hypotension. The referring physicians accepted 100% of the pharmacists' therapeutic recommendations. Unnecessary therapy was avoided in 12 of 40 of patients with suspected isolated office hypertension (30%), and more aggressive treatment was started in 6 of 7 of patients with type 2 diabetes (87.5%). CONCLUSIONS: This project shows that a 24-hour ABPM consultation service can provide useful information for determining which patients have isolated office hypertension and in guiding drug regimen modification for patients with diabetes, suspected resistant hypertension, or drug-induced alterations in blood pressure.