Information from primary care: its importance and value. A comparison of information from Slovenia and England and Wales,viewed from the 'Health 21' perspective

BACKGROUND: The WHO have set health standards in the form of 21 targets--Health 21--and the EU are developing a set of health indicators whereby national health status can be measured. Data from Slovenia and from England and Wales assessing information systems in primary care and their capacity to deliver the requirements of these initiatives have been examined. In both countries, primary care is provided through a state-led service. METHODS: Consultation data from the annual report of the Department of Health Slovenia (1999) are compared in respect of relevant targets with data from the Fourth National Morbidity Survey (1992) in England and Wales. Consultation rates were standardized to the European Union 15 country population (1998). RESULTS: Consultation rates in females were similar in the two countries whereas in males rates were higher in Slovenia. The proportionate distributions of consultations by chapter of the International Classification of Diseases (ICD) were similar in both countries, respiratory (17%) and musculoskeletal (9%) disorders ranked first and second. For eye diseases, injury and poisoning, factors influencing health status (e.g. medical examination). proportions were higher in Slovenia: for mental disorders higher in England and Wales. The relativity of male to female consultation rates was broadly similar with higher rates in females in most ICD chapters. These differences are considered in detail against the background of WHO targets. CONCLUSIONS: Data gathered systematically from the surveillance of consultations in primary care are important to the measurement of WHO 'Health 21' targets.     

Scaling-up an Integrated Care for Patients with Non-communicable Diseases: An Analysis of Healthcare Barriers and Facilitators in Slovenia and Belgium

IntroductionAlthough the concept of integrated care for non-communicable diseases was introduced at the primary level to move from disease-centered to patient-centered care, it has only been partially implemented in European countries. The aim of this study was to identify and compare identified facilitators and barriers to scale-up this concept between Slovenia and Belgium.MethodsThis was a qualitative study. Fifteen focus groups and fifty-one semi-structured interviews were conducted with stakeholders at the micro, meso and macro levels. In addition, data from two previously published studies were used for the analysis. Data collection and analysis was initially conducted at country level. Finally, the data was evaluated by a cross-country team to assess similarities and differences between countries.ResultsFour topics were identified in the study: patient-centered care, teamwork, coordination of care and task delegation. Despite the different contexts, true teamwork and patient-centered care are limited in both countries by hierarchies and a very heavily skewed medical approach. The organization of primary healthcare in Slovenia probably facilitates the coordination of care, which is not the case in Belgium. The financing and organization of primary practices in Belgium was identified as a barrier to the implementation of task delegation between health professionals.ConclusionsThis study allowed formulating some important concepts for future healthcare for non-communicable diseases at the level of primary healthcare. The results could provide useful insights for other countries with similar health systems.     

Putting People First: A Primary Health Care Success in Rural India

Background:

The World Health Report, 2008, contains a global review of primary health care on the 30th anniversary of the Declaration of Alma-Ata. The period covered by the study reported on here corresponds with that of the Report, allowing for a comparison of achievements and challenges in one primary health care centre vis-a-vis the WHO standards.

Materials and Methods:

This study uses qualitative and quantitative data from a rural primary care facility in Western Maharashtra, collected over three decades. It analyzes the four groups of reforms defined by WHO in the context of the achievements and challenges of the study facility.

Results:

According to the WHO Report, health systems in developing countries have not responded adequately to people’s needs. However, our in-depth observations revealed substantial progress in several areas, including in family planning, safe deliveries, immunization and health promotion. Satisfaction with services in the study area was high.

Conclusion:

Adequate primary health care is possible, even when all recommended WHO reforms are not fully in place.     

Changes in primary health care centres over the transition period in Slovenia

BACKGROUND: Primary health care centres (PHCCs) were a characteristic of the former Yugoslav health care system introduced widely in Slovenia. Transition brought structural changes to health care and the position of the PHCC's was challenged. This paper investigates (i) PHCCs' perception of transition changes in health care, (ii) changes in resources and services, and (iii) changes in the relationships between PHCCs and new primary health care providers. METHODS: We mailed a self-administered questionnaire with 42 questions divided into 8 chapters and related to the period between 1990 and 2000 to all 65 PHCCs in Slovenia. Questions were of three types, grouped according to the aspects we were trying to explore: perceived changes, actual changes and relations with new providers. RESULTS: We obtained 57 questionnaires representing PHCC catchment areas covering 93.7% of the Slovenian population. Municipalities' position versus PHCCs was reinforced but their role remains ambiguous. The number of employees was reduced by one third, capital investments are still ongoing, but the scope and volume of services has shrunk. Relations with the Health Insurance Institute of Slovenia (HIIS) were considered controversial while the influence of the public providers' association is perceived as marginal. CONCLUSIONS: PHCCs have survived the transition both structurally as well as functionally. However, an unstructured approach to system changes in primary care, a poorly managed process of introducing private provision, and a monopoly position of the HIIS affected their situation. The challenges for the future will be in preserving their public health functions, in increasing efficiency and in establishing clearly defined relations with private providers.     

The Sustainable Development Agenda Needs to Include Long-term Care

The rapid ageing of populations around the world and the associated shift in the burden of disease from infectious to chronic conditions are creating complex challenges for national governments. Addressing the needs of these older populations in a sustainable and equitable way, will be a fundamental pillar of socioeconomic development in the 21^st Century.The World Health Organization (WHO) Global strategy and action plan on ageing and health, which was adopted by all the Organization’s 194 Member states in 2016, provides a clear framework for global action. One critical priority is to establish sustainable and equitable long-term care systems in every country. WHO defines long-term care as “the activities undertaken by others to ensure that people with, or at risk of, a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity”. These activities include both social care and health care, as well as contributions from other sectors, such as education or transport. And these activities need to be effectively coordinated if they are to efficiently, equitably and sustainably meet the needs of older people. This requires the stewardship of governments to ensure that: care is accessible and affordable; the rights of older people to lives of meaning and dignity are upheld regardless of their physical or mental capacity; services are oriented around the individual’s specific needs; caregivers are supported; the workforce (both paid and unpaid) are treated fairly; and older people’s intrinsic capacity is maintained for as long as possible.WHO has proposed three inter-related strategies to establish and sustain long-term care systems. System infrastructure needs to be developed and continually improved. The capacity of the workforce needs to be strengthened and families and communities must be supported. And the care and support provided needs to be more person-centred and integrated, underpinned by minimum standards and accreditation for care providers. This paper outlines some of the critical issues confronting governments in countries at all levels of development if this ambitious vision is to be achieved.     

Primary Care System Factors and Clinical Decision-making in Patients that Could Have Lung Cancer: a Vignette Study in Five Balkan Region Countries

IntroductionLung cancer is the leading cause of cancer death, with wide variations in national survival rates. This study compares primary care system factors and primary care practitioners’ (PCPs’) clinical decision-making for a vignette of a patient that could have lung cancer in five Balkan region countries (Slovenia, Croatia, Bulgaria, Greece, Romania).MethodsPCPs participated in an online questionnaire that asked for demographic data, practice characteristics, and information on health system factors. Participants were also asked to make clinical decisions in a vignette of a patient with possible lung cancer.ResultsThe survey was completed by 475 PCPs. There were significant national differences in PCPs’ direct access to investigations, particularly to advanced imaging. PCPs from Bulgaria, Greece, and Romania were more likely to organise relevant investigations. The highest specialist referral rates were in Bulgaria and Romania. PCPs in Bulgaria were less likely to have access to clinical guidelines, and PCPs from Slovenia and Croatia were more likely to have access to a cancer fast-track specialist appointment system. The PCPs’ country had a significant effect on their likelihood of investigating or referring the patient.ConclusionsThere are large differences between Balkan region countries in PCPs’ levels of direct access to investigations. When faced with a vignette of a patient with the possibility of having lung cancer, their investigation and referral rates vary considerably. To reduce diagnostic delay in lung cancer, direct PCP access to advanced imaging, availability of relevant clinical guidelines, and fast-track referral systems are needed.     

卫生服务购买的基本理论与模式

结合国际卫生服务领域改革与发展的趋势,并根据 WHO 提出的将战略性购买作为主要的改革策略,从消极性购买转移到战略性购买的发展过程,系统阐述了卫生服务购买的基本概念、理论基础与模式,以及改革成功的经验与发展趋势,为深化我国卫生服务体制改革提供了一个全新的理念与路径选择模式。     

居民就医选择与基层医疗机构的竞争性分析

目的探索影响城乡居民选择基层医疗机构就诊的影响因素,并为基层医疗机构发展提出建议。方法采用Logistic回归对中国健康与营养调查2009年截面数据进行分析。结果疾病严重程度、医疗保险状况、有无工作以及户籍是影响居民选择基层医疗机构就诊的关键因素。结论应当针对这些方面对目前政策做出调整以增强基层医疗机构竞争力。     

卫生服务综合评价模型的研究

本文利用1993年国家卫生服务总调查65个农村样本县的调查资料,计算出3个卫生服务复合评价指标,并利用其3个指标建立了一个三维卫生服务综合评价模型,以此模型评价了65个样本县的卫生服务综合利用情况,结果与客观实际比较吻合。卫生服务三维综合评价模型较WHO推荐的三维模型具有更多的优点和实用性。     

Community Care in Practice

SUMMARY

This paper examines the establishment of social work within primary health care settings in Great Britain, following the passage of the National Health Service and Community Care Act in 1990. Although the improvement of relationships between social workers and primary health care teams has been promoted for a number of years, the advent of formal policies for community care has made this a priority for both social services and health. This paper presents interim findings from the evaluation of three pilot projects in Nottinghamshire, Great Britain. These findings are analysed from three linked perspectives. The first is the extent to which structures and organisations have worked effectively together to promote the location of social workers within health care settings. The second is the impact of professional and cultural factors on the work of the social worker in these settings. The third is the effect of interpersonal relationships on the success of the project. The paper will conclude that there is significant learning from each of these perspectives which can be applied to the future location of social workers to primary health care.     

Preventive Psychology in Primary Care Settings

This article will describe some of the more promising types of preventive interventions that exist in primary health care settings. It will present a rationale for practicing psychologists to consider issues of prevention when working in health care settings. Approaches to prevention and the integration of preventive measures into primary care will be presented, as well as examples of the implementation of innovative prevention programs. This article will conclude with examples and recommendations for primary care psychologists who wish to become more involved with prevention.Editors Strategic Implications: The authors provide useful information and suggestions both for individual psychologists interested in focusing on individual-level interventions, as well as larger-scale interventions that present more challenges to implement, but also provide greater benefits to community health and well-being. Health care professionals and administrators could discern why and how to involve psychologists in their prevention efforts.     

Managed Care, Access to Specialists, and Outcomes among Primary Care Patients with Pain

Objective. To determine whether managed care controls were associated with reduced access to specialists and worse outcomes among primary care patients with pain.
Data Sources/Study Setting. Patient, physician, and office manager questionnaires collected in the Seattle area in 1996–1997, plus data abstracted from patient records and health plans.
Study Design. A prospective cohort study of 2,275 adult patients with common pain problems recruited in the offices of 261 primary care physicians in Seattle.
Data Collection. Patients completed a waiting room questionnaire and follow-up surveys at the end of the first and sixth months to measure access to specialists and outcomes. Intensity of managed care controls measured by plan managed care index and benefit/cost-sharing indexes, office managed care index, physician compensation, financial incentives, and use of clinical guidelines.
Principal Findings. A financial withhold for referral was associated with a lower likelihood of referral to a physician specialist, a greater likelihood of seeing a specialist without referral, and a lower patient rating of care from the primary physician. Otherwise, patients in more managed offices and with greater out-of-network plan benefits had greater access to specialists. Patients with more versus less managed care had similar health outcomes, but patients in more managed offices had lower ratings of care provided by their primary physicians.
Conclusions. Increased managed care controls were generally not associated with reduced access to specialists and worse health outcomes for primary care patients with pain, but patients in more managed offices had lower ratings of care provided by their primary physicians.     

Care management for depression in primary care practice: findings from the RESPECT-Depression trial

PURPOSE This qualitative study examined the barriers to adopting depression care management among 42 primary care clinicians in 30 practices.METHODS The RESPECT-Depression trial worked collaboratively with 5 large health care organizations (and 60 primary care practices) to implement and disseminate an evidence-based intervention. This study used semistructured interviews with 42 primary care clinicians from 30 practice sites, 18 care managers, and 7 mental health professionals to explore experience and perceptions with depression care management for patients. Subject selection in 4 waves of interviews was driven by themes emerging from ongoing data analysis.RESULTS Primary care clinicians reported broad appreciation of the benefits of depression care management for their patients. Lack of reimbursement and the competing demands of primary care were often cited as barriers. These clinicians at many levels of initial enthusiasm for care management increased their enthusiasm after experiencing care management through the project. Psychiatric oversight of the care manager with suggestions for the clinicians was widely seen as important and appropriate by clinicians, care managers, and psychiatrists. Clinicians and care managers emphasized the importance of establishing effective communication among themselves, as well as maintaining a consistent and continuous relationship with the patients. The clinicians were selective in which patients they referred for care management, and there was wide variation in opinion about which patients were optimal candidates. Care managers were able to operate both from within a practice and more centrally when specific attention was given to negotiating communication strategies with a clinician.CONCLUSIONS Care management for depression is an attractive option for most primary care clinicians. Lack of reimbursement remains the single greatest obstacle to more widespread adoption.     

Effect of Primary Care Visits on the Demand for Specialty Care in Health Maintenance Organizations

Health maintenance organizations (HMOs) provide low cost access to primary care physicians (PCPs) in an effort to restrict expensive specialty use. Although managed care plans hope that low cost primary care will reduce specialist use, the theoretical effect of easing access to primary care on specialty use is unclear. Despite the importance of estimating the effect of PCP visits on specialty use, no previous studies have directly addressed this question at the enrollee level. This study examines the effect of visits to the PCP on the demand for episodes of specialty care in two health plans: a gatekeeper HMO and a point-of-service plan. Using person-level data, we estimate a generalized method of moments model of specialty episodes that accounts for the endogeneity of PCP visits within a count-data framework. We compare this model to three alternative models—an OLS model, a negative binomial model, and a two-stage least squares model. We find evidence that increases in primary care visits increase episodes of specialty care in both plans. We also find that the three alternative models yield biased but more efficient estimates compared to the generalized method of moments model.This revised version was published online in June 2005 with a corrected cover date.     

Achieving Value in Primary Care: The Primary Care Value Model

The patient-centered medical home (PCMH) model provides a compelling vision for primary care transformation, but studies of its impact have used insufficiently patient-centered metrics with inconsistent results. We propose a framework for defining patient-centered value and a new model for value-based primary care transformation: the primary care value model (PCVM). We advocate for use of patient-centered value when measuring the impact of primary care transformation, recognition, and performance-based payment; for financial support and research and development to better define primary care value-creating activities and their implementation; and for use of the model to support primary care organizations in transformation.     

医疗之家及其对我国卫生管理的借鉴意义

扩大基本卫生服务是改善群体健康、减低医疗花费的重要举措.介绍了美国当前被广泛推崇的—种基本卫生服务理念——医疗之家（patient centered medical home,PCMH）,详细分析了其特点及实施过程,并探讨了PCMH在我国基本卫生管理中的应用前景.     

我国区县级医院药房药学服务研究

目的:了解我国区县级医院药房药学服务现状,为其提升药学服务水平提供参考。方法:采用WHO的部分指标对医院药房药学服务行为进行定量研究。结果:(1)处方药物种数与所发药物种数2个指标有相关关系,其他指标两两之间无相关关系。(2)我国发药时间、病人姓名标识率和服药时间标识率分别是77.92秒、62.91%和61.84%,与国外的研究值相当;单张处方平均药物种数是4.16种,比国外的研究值高;药物实际分发比例是99.52%,比国外的情况好;药品通用名标识率低,只有40.58%;患者完全知道药物使用方法比例是71.04%,情况比较好。结论:应尽快制定标准药学服务指南,提升我国区县级医院药房药学服务水平。     

Mental Health in Primary Care: Perceptions of Augmented Care for Individuals With Serious Mental Illness

Individuals with serious mental illness are at increased risk of developing secondary physical illnesses because of lifestyle and psychiatric treatment–related factors. Many individuals with mental illness participate in primary care clinics, such as Placer County Community Clinic (PCCC), which provides primary care and medication-only psychiatric services to low-income county residents. This qualitative study describes an augmented care program provided to this population at PCCC and explores participant experiences with that program. The augmented program consisted of a full-time social worker and part-time registered nurse working as a team to coordinate care between providers, and provide psychosocial education and illness management support. Previous studies have demonstrated that similar programs result in improved clinical outcomes for people with mental illness but have largely not included perspectives of participants in these pilot programs. This article includes participant reports about medical service needs, barriers, and beneficial elements of the augmented program. Medical service needs included the need to provide input in treatment and to be personally valued. Barriers ranged from doubts about provider qualifications to concerns about medication. Elements of the augmented care program that participants found beneficial were those involving care coordination, social support, and weight management support.