Quality of stroke prevention in general practice: relationship with practice organization.

OBJECTIVE: To investigate the relationship between elements of practice organization related to stroke prevention in general practice, and suboptimal preventive care preceding the occurrence of stroke. DESIGN: This study was conducted among 69 Dutch general practitioners in the Rotterdam region. Information on the implementation of elements of practice organization related to stroke prevention was collected by postal questionnaire. Data on the process of patient care were collected by means of chart review and interviews with general practitioners. Cases of stroke (n = 186) were retrospectively audited by an expert panel with guideline-based review criteria. Using logistic regression analysis we investigated the relationship between the probability of suboptimal care delivery and the presence of specific elements of practice organization related to stroke prevention (tailored information systems, formal delegation of preventive tasks, standardization of care). RESULTS: For some elements of practice organization significant relationships with the quality of stroke prevention were found. Suboptimal care was less common among general practitioners with a higher level of noting high risk patients in the patient records (odds ratio 0.30; 95% CI 0.13-0.69, P = 0.01), delegating follow-up visits to support staff (odds ratio 0.42; 95% CI 0.22-0.82, P = 0.01) and compliance with the hypertension guideline (odds ratio 0.57; 95% CI 0.41-0.78, P = <0.001). Except for practice type (general practitioners in health centres less often provided suboptimal care, P = 0.02), no significant relationships with general practitioner and practice characteristics were found. CONCLUSION: This study shows that general practitioners with a higher level of integrated organizational structures for stroke prevention (record keeping, formal delegation of preventive tasks, guideline compliance) are less likely to deliver suboptimal care.     

Update: Primary care is not the same as primary health care, or is it?

As primary health care (PHC) evolves from its original conceptual level enunciated in 1978 at Alma-Ata to its present formal body of knowledge and practice, 2 definitional problems arise: whether PHC is a transient jargon or label attached to nothing or whether the older, more restricted term primary care (PC) is the same as PHC. The 1st problem has been rendered irrelevant, but the 2nd remains unsolved. Some controversy exists in both literature and practice. Some health care professionals, especially general practitioners, use the terms interchangeably. This may be because of historic traditions based on the biomedical model of education and practice. The term primary care is credited to the Lord Dawson report of 1920, concerned with the reorganization of medical services in England which resulted in the setting up of health centers. Since 1960 under the National Health Service, general practitioners provided curative and preventive services on a 1st-contact medical basis and by 1962 the term was used to denote general practice. This tradition could have then spread to other western countries, including the US and to developing countries. To humanize this biomedical model, Engel proposed the biopsychosocial model which takes into account the biomedical aspects of disease, the patients' social context, their perception of illness and the interaction of the physician and the health care system. This increased health awareness contributed to the evolution of PHC, which evolved from small-scale experiments. A graphic representation of the relationship between primary (medical) care and primary health care illustrates the various consumer levels and the health care system. The multi-disciplinary concept of primary health care is not interchangeable with primary care.     

General practitioners’ perceptions of their role in cancer follow-up care: A qualitative study in the Netherlands

Background: In the last few decades there has been a considerable increase in the number of cancer survivors. Health policy makers would like to see cancer follow-up care moved from secondary to primary care. Method: Between 2008 and 2010, a qualitative study among primary health care professionals was performed to get more insight into the way they care for cancer survivors. Analysed was whether a coordinating role in cancer survivorship care would fit in with the practical logic underlying the way the general practitioners work. Results: In their everyday work, general practitioners are used to provide care in a reactive way. Based on this habitus, they classify their patients into ‘not special’ and ‘special’ ones. Since general practitioners label cancer survivors as ‘not special,’ they expect these patients to take the initiative to ask for help and present their complaints in a clear and complete way. Their habitus as a gatekeeper implies that they are reticent about referring patients to other primary health care professionals. In regard to ‘not special’ patients, such as cancer survivors, general practitioners appear to build on the patients’ own strengths.

Conclusion: The emphasis on a wait-and-see attitude in contemporary Dutch general practice, as well as the general practitioners’ role as a gatekeeper are at odds with the proactive and holistic approach inherent to a coordinating role in cancer follow-up. Therefore, we assume that it will be difficult for general practitioners to shape a pivotal role in this care.     

Increasing dietetic referrals: Perceptions of general practitioners,practice nurses and dietitians

Aim: To examine Australian private practice dietitians' relationships with general practitioners and practice nurses as a factor that influences dietetic referrals. Methods: Semistructured telephone interviews and an online survey were conducted with Australian private practice dietitians (n = 52 and n = 90, respectively) between April and May 2008. Semistructured questionnaires were conducted with general practitioners (n = 11) and practice nurses (n = 12) from the ‘GP Access’ Division of General Practice between March and July 2007. Results: General practitioners' relationships with dietitians were believed to be the primary influencing factor on referral, provided by 81% of survey dietitians and 25% of interview dietitians. The most common means of initially forming relationships with general practitioners were face‐to‐face introduction (48%) and introductory letters (37%). Patient feedback via letter, fax or email was the most popular method of maintaining relationships with general practitioners (77%). Meeting with general practitioners in person was believed to be the most effective activity in building relationships with general practitioners and increasing referral rates (42%). Referral was made easier for general practitioners by providing paper (37%) or electronic (19%) referral forms and contact details (19%). The majority of general practitioners and dietitians believed that the ‘Allied Health Services Under Medicare’ made it easier to refer to a dietitian. Conclusions: Dietetic referrals can be encouraged through good relationships between general practitioners, practice nurses and dietitians. Private practice dietitians would benefit from cultivating relationships with general practitioners and practice nurses through personal contact and providing good patient feedback.     

Patient evaluations of accessibility and co‐ordination in general practice in Europe

Objective  To determine whether patient evaluations of the accessibility to general practice and co‐ordination with other care providers were associated with characteristics of general practice organizations. Background  In 1998 patients across Europe perceived that small general practices have better accessibility than large practices. Since then a number of changes in primary care have had impact on accessibility and co‐ordination of care. Design, setting and participants  The study was based on data from the European Practice Assessment study, an observational study in 284 general practices in 10 countries in 2004. Main outcome measures  Patient evaluations of general practice were measured with the 23‐item Europep instrument, from which seven items on accessibility and co‐ordination were selected in a principal factor analysis. Six practice characteristics were examined: percentage of female general practitioners, mean age of physicians, mean number of physician hours worked per week, number of general practitioners, number of care providers, urbanization level. Mixed regression models were applied, in which patients were clustered within practices, and practices within countries. Results  Practices with a higher numbers of care providers received less positive patient evaluations (b = −0.112, P = 0.004). The other practice characteristics were not related to patient evaluations. Only a small proportion of the total variation in patient evaluations of accessibility and co‐ordination (1.8%) was explained by characteristics of the general practice organizations. Conclusions  General practices have become larger in most developed countries in recent years, but patients seemed to prefer general practice organizations with fewer health professionals.     

Optimizing the care of patients with depression in primary care: the views of general practitioners

Depression is a very common mental illness within the general population and in-patients consulting in general practice. General practitioners are well placed to provide care for patients with mental health problems, as these disorders are often connected with family and social problems, and GPs can provide their patients with long-term follow-up and support. While there are theoretical reasons for the important role of the family doctor, there is limited evidence about how general practitioners view their roles and their capacity to cope with the mental health needs of their patients. This paper explores the experience of 15 general practitioners from Scotland, who were interviewed during the spring of 1998, about how they approached the care of patients with depression in relation to their skills, knowledge and attitudes. The following four key categories of interest are presented which underpin the emergent themes of the study: (1) organizational issues; (2) referral and the use of other professionals; (3) treatment and management issues; (4) stigma. These themes reveal some interesting issues in relation to GPs' recognition and management of depression and it is also clear that the perception of collaboration within primary care and between primary and secondary care is an integral part of the process. The implications of what has been learned from this study may include the development of educational opportunities for GP trainees and established principals, in addition to brief multidisciplinary training opportunities and shared learning events between primary and secondary care.     

Asthma management in rural New South Wales: Perceptions of health care professionals and people with asthma

Objective:  To investigate the perceptions and attitudes towards asthma management of general practitioners, pharmacists and people with asthma in a rural area.
Design:  Qualitative semistructured interviews.
Setting:  Small rural centre in New South Wales.
Participants:  General practitioners, pharmacists and people with asthma in a rural area.
Results:  General practitioners perceived that the patient provided a barrier to the implementation of optimal asthma services. They were aware that other health care professionals had a role in asthma management but were not aware of the details, particularly in relation to that of the pharmacist and would like to improve communication methods. Pharmacists also perceived the patient to be a barrier to the delivery of optimal asthma management services and would like to improve communication with the general practitioner. The impact of the rural environment for the health care professionals included workforce shortages, availability of support services and access to continuing education. People with asthma were satisfied with their asthma management and the service provided by the health care professionals and described the involvement of family members and ambulance officers in their overall asthma management. The rural environment was an issue with regards to distance to the hospital during an emergency.
Conclusions:  General practitioners and pharmacists confirmed their existing roles in asthma management while expressing a desire to improve communication between the two professions to help overcome barriers and optimise the asthma service delivered to the patient. The patient described minimal barriers to optimising asthma management, which might suggest that they might not have great expectations of asthma care.     

Patient empowerment,an additional characteristic of the European definitions of general practice/family medicine

Abstract

Growing evidence supports the inclusion of patient empowerment as a key ingredient of care for patients with chronic conditions. In recent years, several studies based on patient empowerment, have been carried out in different European countries in the context of general practice and primary care to improve management of chronic diseases. These studies have shown good results of the care model, increasing patient and health professionals’ satisfaction, adherence to guidelines and to treatment, and improving clinical outcomes. In 2011, the Wonca European Council included as the twelfth characteristic of the European definitions of general practice/family medicine: ‘promote patient empowerment’. The aim of this paper is to clarify the meaning of 'patient empowerment’ and to explain why family medicine should be considered the most suitable setting to promote it. The inclusion of patient empowerment as one of the essential characteristics of general practice fills a conceptual gap and clearly suggests to the European health care systems a tested model to face chronic diseases: involving and empowering patients in managing their own conditions to improve health and well-being.     

Welfare rights advice in primary care: prevalence,processes and specialist provision

BACKGROUND: Despite persistent poverty-related health inequalities, few sustained responses have been developed in primary care. Welfare rights provision has been proposed as one potential pathway to addressing health inequalities. OBJECTIVES: This study was set up to address the prevalence of welfare rights issues in general practice, and the practitioner response to unmet need. METHODS: A postal questionnaire was sent to practitioners in GP surgeries of an inner city health authority with high levels of deprivation. By means of a 'most recent case audit', data on welfare advice needs were collected. Practices with in-house welfare rights provision were compared with those surgeries with no such provision. RESULTS: Questionnaires were returned by 153 practitioners, describing their most recent case with a welfare rights need (mean 10.41 days ago). Of the respondents, 70.6% felt that there was a mental health element to this consultation, 49.8% of problems were described as urgent, and 65.8% of patients requested information or guidance. Those practitioners with specialist advisers in the surgery (n = 81) were significantly more likely to find referring patients to advisers easy, that quality of advice for patients was good, that welfare providers enhanced their ability to practice effectively and that such provision improves the health and well-being of patients. In those surgeries without provision (n = 72), patients were more likely to approach their practitioner for advice. GPs were more likely than nurses and other practising staff to see a case with welfare rights needs. Practitioners were more likely to raise the welfare issues if they had specialist advice in the surgery. CONCLUSIONS: A large amount of practitioner consultation time is spent on welfare rights-related issues. Although practitioners are skilled in detecting need, and their practice is enhanced by specialist support, expansion is needed to provide the advice which cannot be met by clinical consultation.     

Dietetic care of hip fracture patients across Australia: Are we doing enough?

Aim: To determine the composition of usual nutrition care provided by Australian dietitians to patients with a falls related femoral neck fracture. Methods: A cross‐sectional survey administered via the World Wide Web using SurveyMonkey to dietitians across Australia. Results: One hundred and sixty‐eight dietitians working with patients with a femoral neck fracture in Australia responded to the survey. Few dietitians (n = 7) indicated they worked in the community setting. Nutritional screening was used among respondents (n = 93), but 32/93 indicated they did not use a validated tool. Most commonly used interventions included strategies to increase intake of nutrients, such as provision of nourishing meals, snacks and oral supplements. Conclusions: Some concerns remain regarding provision of optimal nutritional care of femoral neck fracture patients in Australia. There were few respondents working in the community with falls related femoral neck fracture patients, with a greater number of dietitians working in the metropolitan area responding to the survey. The Dietitians working in this area are implementing a great variety of screening methods, with a large number using non‐validated screening tools. Clearer guidelines for health professionals involved in femoral neck fracture aftercare would be beneficial to standardise care in this area. A useful first step for dietitians would be to advocate for the use of evidence‐based practice resources in selection of site and age appropriate nutrition screening tools.     

Position of the American Dietetic Association: Oral health and nutrition

It is the position of the American Dietetic Association (ADA) that nutrition is an integral component of oral health. The ADA supports the integration of oral health with nutrition services, education, and research. Collaboration between dietetics and dental professionals is recommended for oral health promotion and disease prevention and intervention. Scientific and epidemiological data suggest a lifelong synergy between nutrition and the integrity of the oral cavity in health and disease. Oral health is an integral part of systemic and nutritional health. Two primary oral infectious diseases are directly influenced by diet and nutrition. Dental caries or tooth decay is modulated by numerous factors, including diet composition and frequency. Periodontal or gum disease is associated with malnutrition. Chronic diseases such as diabetes and cardiovascular disease that are modulated by diet and nutrition intervention have oral sequelae. As we advance in our discoveries of the links between oral and nutrition health, practitioners of both disciplines must learn to provide screening, baseline education, and referral to each other as part of comprehensive client/patient care. The future of dietetics practice requires dietetics professionals to provide medical nutrition therapy (MNT) that incorporates a person's total health needs, including oral health. Inclusion of both didactic and clinical practice concepts that illustrate the role of nutrition in oral health is essential in both dental and dietetic education programs. Collaborative endeavors between dietetics and dentistry in research, education, and delineation of health provider practice roles are needed to ensure comprehensive health care to persons with oral infectious disease and/or oral manifestations of systemic diseases.     

Feasibility evaluation of a stepped procedure to identify community-dwelling frail older people in general practice. A mixed methods study

Background: Implementation of frailty identification methods in general practice has hardly been established. To achieve successful implementation, general practitioners (GPs) should be provided with an identification method that suits their needs. EASYcare-TOS is a new frailty identification method that uses a stepped approach and is specifically developed for use in general practice. The first step consists of the GP's frailty judgment based on his prior information on the patient. If the judgment is ‘uncertain’ or ‘frail,’ additional data are collected by a primary care nurse (PCN). The frailty decision is based on clinical reasoning by the GP, without applying predefined cut-offs in a numerical score.

Objective: To evaluate the acceptability of EASYcare-TOS in daily general practice.

Methods A mixed-methods study was conducted. Questionnaires were sent to all professionals (n = 25) who participated in the EASYcare-TOS validation study. Subsequently, semi-structured interviews with primary care professionals (n = 12) and patients (n = 9) were conducted.

Results: Time investment was generally perceived as acceptable. Twenty-two professionals (88%) found a two-step model (very) useful in the identification instrument. Seventeen professionals (68%) valued making the final frailty decision by their own clinical reasoning. Patients appreciated the broad assessment and the advice given based on the assessment. According to 24 (96%) professionals, EASYcare-TOS improved the quality of patient care. GPs stated that implementation will ask for reconsidering allocation of tasks in general practices and adequate reimbursement.

Conclusion: EASYcare-TOS is a new identification method that fits the needs of primary care professionals to a large extent and is acceptable in daily practice.     

Patient satisfaction with availability of general practice: an international comparison.

OBJECTIVE: To identify associations between the characteristics of general practitioners and practices, and patients' evaluations of the availability of general practice. DESIGN: Written surveys completed by patients. SETTING: General practice care in nine European countries: Denmark, Germany, The Netherlands, Norway, UK, Belgium (Flanders and Wallonia), Switzerland, Slovenia and Spain. STUDY PARTICIPANTS: 15996 adult patients consecutively visiting the general practitioner (response rates per country varied between 47 and 89%). MAIN MEASURES: The Europep instrument to assess patients' evaluations of five aspects of the availability of general practice care: (1) getting an appointment, (2) getting through on the phone, (3) being able to speak to the practitioner on the telephone, (4) waiting time in the waiting room, and (5) providing quick services for urgent health problems. Each general practitioner recorded age, sex, number of years in the practice, number of practitioners and other care providers in the practice, and urbanization level of the practice. RESULTS: Patients' more positive evaluations were associated with fewer general practitioners in the practice, except for quick services for urgent health problems (range of conditional overall odds ratios, 1.69-2.02). In addition, a number of significant unconditional overall odds ratios were found, particularly those related to the number of general practitioners' working hours and the number of care providers in the practice. None of the associations was found consistently in all countries. CONCLUSION: Patients favour small practices and full-time general practitioners, which contradicts developments in general practice in many countries. Policy makers should consider how the tensions between patients' views and organizational developments can be solved.     

‘It helps me make sense of the world’: the role of an art intervention for promoting health and wellbeing in primary care—perspectives of patients, health professionals and artists

Background

Art interventions are increasingly used in public health for the enhancement of patients’ health and wellbeing. The present study investigated perceived outcomes and role of an art intervention from the collective perspectives of participants (patients who took part), deliverers (artists) and referrers (general practitioners and practice nurses).

Methods

A qualitative methodology, using interviews and focus groups, allowed investigation of participants (n?=?18) perceived outcomes and role of the intervention. Participants included patients (n?=?10), artists (n?=?5), and referring health professionals (n?=?3).

Results

Themes that emerged from the analysis included perceived benefits, role and value of the intervention, and setting and referral process. Central to these themes were psychological and mental health benefits, an appreciated holistic treatment option and the merits of the intervention being situated in the surgery setting.

Conclusions

The study showed that art interventions within primary care are valuable in the promotion of public health, and in particular, patients’ mental health. Interactions between other participants and the artist were central to achieving patients’ perceived health improvement. Locating the intervention in primary care facilitated patient participation and provided health professionals with a holistic treatment alternative. There is also some evidence that participation in the intervention encourages less dependence on the health professional.     

Sharing care between hospital and the community: a critical review of developments in the UK

Recent changes in health policy in the United Kingdom have emphasized the key importance of a collaborative and multidisciplinary approach to the organization of health care. These changes have resulted in the formulation of programmes of shared care involving professionals from all areas of institutional and community practice. This paper critically explores the literature relating to shared care between hospital consultants and general practitioners (GPs) in the UK. The paper takes as its focus some clinical conditions for which shared care arrangements have been put into effect, and the implications of shared care for prescribing practice are discussed.     

The Use of Behavior Change Theories in Dietetics Practice in Primary Health Care: A Systematic Review of Randomized Controlled Trials

BackgroundBehavior change theories frameworks provide the theoretical underpinning for effective health care. The extent to which they are applied in contemporary dietetics interventions has not been explored.ObjectiveTo systematically review the evidence of behavior change theory-based interventions delivered by credentialed nutrition and dietetics practitioners in primary health care settings.MethodsMedline, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Embase, and Cochrane databases were searched for English language, randomized controlled trials before August 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. Eligible interventions included adults (aged ≥18 years) receiving face-to-face dietetics care underpinned by behavior change theories in primary health care settings with outcome measures targeting changes in health behaviors or health outcomes. Screening was conducted independently in duplicate and data were extracted using predefined categories. The quality of each study was assessed using the Cochrane Risk of Bias tool. The body of evidence was assessed using the Academy of Nutrition and Dietetics Evidence Analysis Manual Conclusion Grading Table.ResultsThirty articles reporting on 19 randomized controlled trials met the eligibility criteria, representing 5,172 adults. Thirteen studies (68%) showed significant improvements for the primary outcome measured. Social cognitive theory was the behavior change theory most commonly applied in interventions (n=15) with 11 finding significant intervention effects. Goal setting, problem solving, social support, and self-monitoring were the most commonly reported techniques (n=15, n=14, n=11, and n=11, respectively). Most studies had a high (n=11) or unclear (n=8) risk of bias. There was fair evidence (Grade II) supporting the use of behavior change theories to inform development of dietetics interventions.ConclusionsInterventions delivered by credentialed nutrition and dietetics practitioners that were underpinned by behavior change theories and utilizing various behavior change techniques were found to have potential to be more effective at improving patient health outcomes than dietary interventions without theoretical underpinnings. Findings from this review should inform future primary health care research in the area of dietary behavior change. In addition, findings from this review highlight the need for stronger documentation of use of behavior change theory and techniques that map on to the theory within dietetics practice.     

Case-based training of evidence-based clinical practice in primary care and decreased mortality in patients with coronary heart disease

PURPOSE We investigated the 10-year mortality rates in a trial that tested a case-based intervention in primary care aimed at reducing the gap between evidence-based goals and clinical practice in patients with coronary heart disease (CHD).METHODS A prospective randomized controlled pragmatic trial was undertaken in a primary care setting. New evidence-based guidelines, with intensified lipid-lowering recommendations in CHD, were mailed to all general practitioners in the region and presented at a lecture in 1995. General practitioners (n = 54) and patients with CHD (n = 88) were assigned according to their primary health care center to 2 balanced groups and randomly allocated to usual care as a control or to an active intervention. General practitioners in the intervention group participated in repeated case-based training during a 2-year period. Patients whose CHD was treated by specialists (n = 167) served as an internal specialist comparison group. Altogether, 255 consecutive patients were included. Cox regression analysis was used to detect any survival benefit of the intervention.RESULTS At 10 years, 22% of the patients in the intervention group had died as compared with 44% in the control group (P = .02), with a hazard ratio of 0.45 (95% confidence interval, 0.20–0.95). This difference was mainly due to reduced cardiovascular mortality in the intervention group (P = .01). In addition, the mortality rate of 22% in the intervention group was comparable to the rate of 23% seen in patients treated by a specialist.CONCLUSIONS Use of case-based training to implement evidence-based practice in primary care was associated with decreased mortality at 10 years in patients with CHD.     

General practice care and patients' priorities in Europe: an international comparison.

Insight into patients' priorities with respect to health care should complement the views of professionals and policy makers on what is thought to be appropriate health care. To determine the strengths and weaknesses of general practice care from patients' perspectives written surveys were performed among patients in Denmark, Germany, Israel, Netherlands, Norway, Portugal, Sweden and United Kingdom (n = 3540). The potential quality problems identified were spread over the different countries: the low involvement of general practitioners in out-of-hours services in Portugal; the low provision of routine screening in Sweden, Norway and The Netherlands; the lack of a defined patient population in Germany; the lack of a formal gatekeeper role to secondary care in general practice in Germany and Sweden; and the low number of home visits in Sweden.     

Position of the Academy of Nutrition and Dietetics: Oral Health and Nutrition

It is the position of the Academy of Nutrition and Dietetics that nutrition is an integral component of oral health. The Academy supports integration of oral health with nutrition services, education, and research. Collaboration between dietetics practitioners and oral health care professionals is recommended for oral health promotion and disease prevention and intervention. Scientific and epidemiological data suggest a lifelong synergy between diet, nutrition, and integrity of the oral cavity in health and disease. Oral health and nutrition have a multifaceted relationship. Oral infectious diseases, as well as acute, chronic, and systemic diseases with oral manifestations, impact an individual's functional ability to eat and their nutrition status. Likewise, nutrition and diet can affect the development and integrity of the oral cavity and progression of oral diseases. As knowledge of the link between oral and nutrition health increases, dietetics practitioners and oral health care professionals must learn to provide screening, education, and referrals as part of comprehensive client/patient care. The provision of medical nutrition therapy, including oral and overall health, is incorporated into the Standards of Practice for registered dietitians and dietetic technicians, registered. Inclusion of didactic and clinical practice concepts that illustrate the role of nutrition in oral health is essential in education programs for both professional groups. Collaborative endeavors between dietetics, dentistry, medicine, and allied health professionals in research, education, and delineation of practice roles are needed to ensure comprehensive health care. The multifaceted interactions between diet, nutrition, and oral health in practice, education, and research in both dietetics and dentistry merit continued, detailed delineation.