Teaching community-oriented primary care (COPC): A practical approach

To improve education in community-oriented primary care (COPC) and to promote its practice in the community, the University of California's School of Public Health in Berkeley and School of Medicine in San Francisco are collaborating in an innovative program in cooperation with several federally-funded community clinics in the San Francisco Bay Area. The School of Public Health designed a COPC track for graduate public health students from various departments of the school who wished to work in community health care. The track includes a seminar given in the spring of the students' first year in which COPC theory is taught and teams of students working with a faculty advisor and a clinic preceptor design COPC projects for the primary care sites. These projects are then implemented in the summer and fall by students who elect to use this experience to satisfy their fieldwork requirement. This paper is a report of the first year's experience with this collaborative effort.Emilie H.S. Osborn, M.D., M.P.H. is Assistant Professor, Family and Community Medicine, University of California at San Francisco. Norman Hearst, M.D., M.P.H. is Assistant Clinical Professor, Clinical Epidemiology and Family and Community Medicine, University of California at San Francisco. Joyce C. Lashof, M.D., is Dean, School of Public Health, University of California at Berkeley. W. McFate Smith, M.D., M.P.H. is Director, Preventive Medicine Residency, School of Public Health, University of California at Berkeley.This project has been supported in part with Federal funds from the Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Public Health Service, under contract #240-84-0124. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services.     

Exposure to second-hand smoke in primary health care centres in Catalonia, Spain (2006)

The aim of this study was to assess the exposure to second-hand smoke (SHS) in 90 primary health care centres in Catalonia, Spain. We conducted a cross-sectional study between March and October 2006. We measured vapour-phase nicotine as a marker of SHS in main halls, staff rooms, direction areas, and continued care. Sampler devices were exposed for 7 days, and samples were analysed by gas chromatography/mass spectrometry. We compared the median airborne nicotine concentrations with the non-parametric test for medians by sanitary region, sampled location, affiliation to the Smoke-free Primary Health Care Programme, and urban-rural area. From 300 sampler devices installed, 4 were lost, and detectable levels of nicotine were found in 89 samples (30.0%) in 48 different centres (53.3%). The overall median was 0.01 μg/m³, with an interquartile range (IQR) of 0.01-0.07 μg/m³. Median nicotine levels by locations were: reception hall 0.01 μg/m³ (IQR: 0.01-0.06); staff room 0.01 μg/m³ (IQR: 0.01-0.08); direction area 0.01 μg/m³ (IQR: 0.01-0.01); continued care 0.01 μg/m³ (IQR: 0.01-0.07). Results showed that airborne nicotine levels were very low, with 46.7% of primary health centres being free of SHS.     

Family medicine in Cuba: community-oriented primary care and complementary and alternative medicine

Family physicians in Cuba and the United States operate within very different health systems. Cuba's health system is notable for achieving developed country health outcomes despite a developing country economy. The authors of this study traveled to Cuba and reviewed the literature to investigate which practices of Cuban family physicians might be applicable for US family physicians wishing to learn from the Cuban experience. We found that community-oriented primary care (COPC) and complementary and alternative medicine (CAM) are well developed within the Cuban medical system. Because COPC and CAM are already recommended by US family medicine professional bodies, US family physicians may want to learn from the Cuban experience and perhaps incorporate elements into their individual practices.     

Patients and community together. A family medicine community-oriented primary care project in an urban private practice

BACKGROUND: There has been considerable discussion in the literature regarding the value and feasibility of community-oriented primary care (COPC), but relatively few published real-world examples. OBJECTIVE: To examine the effect of a practice-based COPC project on rates of preventive health interventions within an inner-city family medicine practice. METHODS: A newly created community advisory board called Patients and Community Together (PACT) and the medical director of the practice in Rochester, NY, collaborated on all phases of the COPC project. Papanicolaou smear and mammography screening, childhood immunizations, diabetes control, and smoking cessation were targeted for intervention. A practice/community awareness campaign was instituted and individual and group incentives were developed. Progress was monitored through a computerized medical record that included all active patients in the practice. RESULTS: Rates of annual Papanicolaou smears increased from 46% to 71%; annual mammography for women older than age 50 years, from 56% to 86%; completed childhood immunizations when younger than 6 years, from 78% to 97%; and performance of semiannual glycosylated hemoglobin, from 85% to 92%. Rates of patients with glycosylated hemoglobin values under 10% improved from 56% to 77%. There were 5 smokers who successfully quit. CONCLUSION: This project illustrates how practice-based COPC can be successfully implemented within a private practice setting. It also shows how COPC principles can be used to achieve the goals for Healthy People 2000 within inner-city practices.     

Working conditions of public health workers in the primary care in Catalonia, Spain

OBJECTIVE: To describe the working conditions and tasks of health workers in the health training unit of family medicine in Catalonia, Spain. METHODS: Cross-sectional study. RESULTS: Fifty-three public health workers were located. Forty responses were obtained, of which 29 were complete. More than half the health technicians in the Catalan Health Service had temporary contracts. Their main tasks were teaching, providing methodological assistance in research, and auditing healthcare services and healthcare workers. Health technicians wanted more precise job definition and better working conditions. Although a small proportion believed coordination of primary care and public health to be very difficult, most would take part in it. CONCLUSIONS: The main issues for public health workers were work instability, better salaries, and greater job definition. Coordination between primary care and public health was considered desirable.     

Implementing community-oriented primary care projects in an urban family practice residency program

BACKGROUND: Clinics interested in pursuing community-oriented primary care (COPC) have struggled with the implementation of its theory. Although we are still early in the COPC transformation process, the HealthPartners Family Practice Residency Program has had several successful COPC projects during our 10 years of experience. This article describes these projects and the 8 lessons learned, including some that differ from traditional COPC teaching and practice. In our experience, clinics should select a topic or problem that creates a passion within their clinic. Projects can start small within the clinic and expand outward into larger portions of the urban community. Partnerships begin the process of extending into the community and increasing the project's impact. The evaluation of projects should begin with clinic-based data. A physician champion and a nonphysician staff person increase the success of the project. Resident involvement is enhanced with concrete tasks and community connections. Ultimately, the project needs to be institutionalized within the clinic to survive. The whole COPC endeavor is a long, slow process that requires time, energy, and committed individuals. In our experience, COPC is a journey, not an end, and there are many rich rewards to be found along the way.     

Gender inequalities in health and health care services use in Catalonia (Spain)

BACKGROUND AND OBJECTIVES: While socio-economically derived differences in health and health services use have long been a subject of study, differences based on gender, considered as the explicative variable, have scarcely been quantified from population-based data. The aim of this investigation was to analyse inequalities in health and health care services utilisation between men and women in Catalonia (Spain). DESIGN, SETTING, PARTICIPANTS, AND MEASURES: Data from the Catalan Health Interview Survey, a cross sectional survey conducted in 1994, were used. A total of 6604 women and 5641 men aged 15 years or over were included for analysis. Health related variables studied were self perceived health, restriction of activity (past two weeks), and presence of chronic conditions; health services use variables analysed were having visited a health professional (past two weeks), an optometrist (12 months), or a dentist (12 months); and hospitalisation (past 12 months). Age standardised proportions were computed according to gender, and prevalence odds ratios (OR) were derived from logistic regression equations. MAIN RESULTS: Women more frequently rated their health as fair or poor than men (29.8% v 21.4%; OR = 1.22; 95% CI: 1.10, 1.34). More women than men reported having restricted activity days (OR = 1.86; 95% CI: 1.59, 2.18) and chronic conditions (OR = 1.74; 95% CI: 1.60, 1.89). The proportion of women visiting a health professional was slightly greater than that for men (OR = 1.20; 95% CI: 1.09, 1.31), as was the proportion of women visiting an optometrist (OR = 1.21; 95% CI: 1.11, 1.33), and a dentist (OR = 1.43; 95% CI: 1.31, 1.55). The proportion of hospitalisation was lower in women (6.6%) than in men (7.7%; OR = 0.73; 95% CI: 0.63, 0.85). When health services use was analysed according to self perceived health, women declaring good health reported a greater probability of consulting a health professional (OR = 1.35; 95% CI: 1.20, 1.52). There were no differences in respect to hospitalisation, visits to the optometrist and to the dentist. CONCLUSIONS: These results indicate a pattern close to the inverse care law, as women, who express a lower level of health and thus would need more health care, are not, however, using health services more frequently than men.     

A pilot program to improve causes of death certification in primary care of Catalonia, Spain

OBJECTIVE: The BEDTAR pilot program assessed changes in the quality of certification of death's causes after a training session for the primary care physicians in the Tarragona's Area of Catalonia, in the Northeast of the Iberian Peninsula. DESIGN: Before-after evaluative study with intervention and without control group. SETTING AND PARTICIPANTS: The study population was the physicians of the reformed primary health care network of the AT. MATERIAL AND METHODS: The training session began with a test consisting of certifying 3 deaths. This test was followed by a theoretical and practical seminar. The session concluded with a final test consisting on certifying the same 3 cases. The variables used to evaluate the quality the certification were: logical sequence the death causes, correct position on death certificate of the immediate, intermediate and basic causes, precise use of cardiac arrest and other ill-defined diseases, appropriate use of abbreviations, legibility, vocabulary and, finally, use of all the available information. RESULTS: The final participation of the study population was 71% and the global program efficacy was 59%. CONCLUSIONS: The BEDTAR program improved the quality of certification and emphasized the relevancy and the applicability of the results.     

Nursing workload predictors in Catalonia (Spain): a home care cohort study

Objective

To identify the characteristics of chronic patients and their environment in order to predict the nursing workload required 1 year after their inclusion in a home care program.

Methods

A longitudinal study was carried out in 72 primary health care teams in Catalonia (Spain) with a 1-year follow-up of 1,068 home care patients over 64 years old. The variables collected from each patient included data on health and social status (Charlson and Barthel indexes and the Pfeiffer, Braden and Gijon scales), carer overburden (Zarit scale), hospital admissions, use of emergency services, self-perceived health (SF-12) and the number of health worker visits.

Results

Patients received 7.2 (SD 10.4) visits per year from their nurse-in-charge, out of a total of 8.7 (SD 13.1) nursing visits per year. Risk factors for receiving more nursing visits at home were male gender (IRR = 1.42, 95%CI: 1.20-1.67), dependency for daily activities (IRR = 1.65, 95%CI: 1.29-2.13), decubitus ulcers (IRR = 4.03, 95%CI: 2.27-7.14) and receiving emergency medical care at home (IRR = 1.65, 95%CI: 1.31-2.07). In contrast, patients with major cognitive impairment (IRR = 0.78, 95%CI: 0.63-0.98) had a lower probability of receiving nursing visits at home.

Conclusions

Workload can be predicted by patients’ clinical characteristics. The positive correlation of workload with variables related to disease severity and the negative correlation with variables related to cognitive impairment show that home care nursing in Catalonia is basically demand-oriented.     

Underreporting of fatal occupational injuries in Catalonia (Spain)

BACKGROUND: Thoroughness in a given health information system is one of its most important quality indicators. In Spain, in approximately 30% of serious occupational injuries, there is no information on the final outcome. AIM: To assess underreporting of fatal occupational injuries in Catalonia. METHODS: All serious occupational injuries (excluding commuting injuries) reported in Catalonia (Spain) between 1994 and 1998 (n = 7330) were linked with data from the Catalonian Mortality Register, 117 deaths being identified during the year following the injury date. In order to assess whether death could or could not have been related to the prior occupational injury, two experts examined these cases independently. RESULTS: The experts concluded (kappa = 0.98) that 69 (59%) of these deaths were probably related to occupational injuries; the vast majority (n = 65) occurred within 3 months of the injury. This represents an accumulated risk of dying of approximately 1% for the total of serious injuries, not varying with economic activity or job category. However, this risk varied depending on the form of accident, and the site and nature of the injury. CONCLUSIONS: Occupational injury cases, especially serious ones, should be followed up over at least 3 months. These results suggest the importance of carrying out active case-finding and of incorporating the death certificate as one of the documents to be systematically reviewed in order to complete the statistics.     

Training physicians for community-oriented primary care in Latin America: model programs in Mexico, Nicaragua, and Costa Rica.

Under the rubrics of preventive and social medicine, public health, and family and community medicine, medical educators in Latin America have developed programs to train physicians for community-oriented health care (COPC). The historical background for such programs in Latin America is reviewed. Three relevant examples of programs in Mexico, Nicaragua, and Costa Rica are highlighted, drawing on the author's direct experience with and in these faculties. The paper addresses the relation between these programs and national and regional trends in education and services.     

Ethical behaviour in clinical practice: a multidimensional Rasch analysis from a survey of primary health care professionals of Barcelona (Catalonia,Spain)

Purpose

Normative ethics includes ethical behaviour health care professionals should uphold in daily practice. This study assessed the degree to which primary health care (PHC) professionals endorse a set of ethical standards from these norms.

Methods

Health care professionals from an urban area participated in a cross-sectional study. Data were collected using an anonymous, self-administered questionnaire. We examined the level of ethical endorsement of the items and the ethical performance of health care professionals using a Rasch multidimensional model. We analysed differences in ethical performance between groups according to sex, profession and knowledge of ethical norms.

Results

A total of 452 Professionals from 56 PHC centres participated. The level of ethical performance was lower in items related to patient autonomy and respecting patient choices. The item estimate across all dimensions showed that professionals found it most difficult to endorse avoiding interruptions when seeing patients. We found significant differences in two groups: nurses had greater ethical performance than family physicians (p < 0.05), and professionals who reported having effective knowledge of ethical norms had a higher level of ethical performance (p < 0.01).

Conclusions

Paternalistic behaviour persists in PHC. Lesser endorsement of items suggests that patient-centred care and patient autonomy are not fully considered by professionals. Ethical sensitivity could improve if patients are cared for by multidisciplinary teams.     

Influenza vaccine coverage, influenza-associated morbidity and all-cause mortality in Catalonia (Spain)

The objective of this work was to study the behaviour of influenza with respect to morbidity and all-cause mortality in Catalonia, and their association with influenza vaccination coverage. The study was carried out over 13 influenza seasons, from epidemiological week 40 of 1994 to week 20 of 2007, and included confirmed cases of influenza and all-cause mortality. Two generalized linear models were fitted: influenza-associated morbidity was modelled by Poisson regression and all-cause mortality by negative binomial regression. The seasonal component was modelled with the periodic function formed by the sum of the sinus and cosines. Expected influenza mortality during periods of influenza virus circulation was estimated by Poisson regression and its confidence intervals using the Bootstrap approach. Vaccination coverage was associated with a reduction in influenza-associated morbidity (p<0.001), but not with a reduction in all-cause mortality (p=0.149). In the case of influenza-associated morbidity, an increase of 5% in vaccination coverage represented a reduction of 3% in the incidence rate of influenza. There was a positive association between influenza-associated morbidity and all-cause mortality. Excess mortality attributable to influenza epidemics was estimated as 34.4 (95% CI: 28.4-40.8) weekly deaths. In conclusion, all-cause mortality is a good indicator of influenza surveillance and vaccination coverage is associated with a reduction in influenza-associated morbidity but not with all-cause mortality.