„Primary Health Care“ und Urbanisierung

Background

The world of the twenty-first century will be a predominantly urban world. By the year 2008, for the first time in human history, more people were residing in cities than in rural areas. The process of urbanization was mostly completed in the industrialized countries by the mid-twentieth century. In developing countries, however, both number and proportion of city dwellers are increasing.

Methods

To review the process of urbanization in developing countries, its relevance for the social and health situation of urban populations and the consequences arising thereof for the concept of Primary Health Care (PHC).

Results

A rapid urbanization poses great challenges to city councils, e. g. concerning infrastructure and distribution of societal wealth. Today, the process of urbanization is accompanied by a lack of jobs in the formal sector and a change in lifestyle which is not conducive to health, e.g. high calorie and fatty foods. A disaggregation of the health situation shows strong intra-city differentials between wealthy neighbourhoods and slum areas. Slum dwellers remain exposed to communicable diseases and are in addition at risk for non-communicable, chronic diseases. Many of the most prevalent health problems have social causes. Such health problems will persist as long as their social causes are not mended. Evidence-based interventions for tackling social causes of illness are lacking, however.

Discussion

Urbanization poses new challenges to PHC. The present strategies, e.g. prevention, are often restricted to health symptoms and reach the middle classes rather than the urban poor. Instead, strategies directed towards a more human urbanization are required. They would have to make full use of the primary health care approach.     

Pediatric Primary Care Providers’ Relationships with Mental Health Care Providers: Survey Results

Background

As many as 20 % of children have diagnosable mental health conditions and nearly all of them receive pediatric primary health care. However, most children with serious mental health concerns do not receive mental health services. This study tested hypotheses that pediatric primary care providers (PPCPs) in relationships with mental health providers would differ in their care of patients with mental health concerns when compared to PPCPs not in such relationships.

Objective

To explore differences between PPCPs who have relationships with mental health care providers and those who do not with regard to their care of children with mental health concerns.

Methods

Seventy-two PPCPs completed a mailed survey addressing topics such as comfort levels diagnosing and managing patients with behavioral health disorders, perceived barriers to care, activity related to prescribing psychotropic medications, and availability of consultation with mental health specialists. More than one-third (19 providers) of providers reported no specialized training in behavioral pediatrics and nearly 45 % (32 providers) indicated having a relationship or partnership with a mental health specialist.

Results

Those providers who reported relationships indicated greater availability of consultation and communication with psychiatric providers as well as telephone consultation with non-psychiatric mental health providers. All providers were more comfortable assessing as opposed to treating children with disorders, with the exception of attention disorders, which providers were comfortable with both treating and assessing. For all conditions, there was no main effect for partnership.

Conclusion

While partnerships may be associated with greater availability of consultation and communication, for this sample of PPCPs there was no evidence of advantage with respect to diagnosis and management. The paper concludes with a discussion of study limitations, the need for further research, and suggestions for practice.     

Should Programs of All-Inclusive Care for the Elderly Use Community-Based Primary Care Physicians?

The program of All-inclusive Care for the Elderly (PACE) is a community-based, long-term care model designed for older adults that are nursing home eligible. Bound by original design and regulations, these programs have primarily utilized a center-based ("staff") primary care physician model. However, some believe that this might hinder expansion of the PACE model. In response to this concern, three PACE programs have explored the use of "community-based" primary care physicians (CBPCPs). In an attempt to evaluate the impact of this variation in the model, we surveyed the medical director, 2 community-based primary care physicians and 6 non-physician staff members at one of these sites. Responders generally support the use of CBPCPs as a useful and productive alternative way to expand PACE services to a wider audience of eligible patients. Because some staff members perceive that CBPCPs utilize hospital and NH services at a higher rate, continued education of both CBPCPs and staff members regarding the expectations from this relationship is needed.     

„Primary Health Care“ und Effizienz der Gesundheitsversorgung

Background

: The Alma-Ata Declaration does not use the term “efficiency.” The economic dimension of health care is mentioned, but economic considerations are not used as rationale for the concept of primary health care (PHC). It is the objective of this paper to demonstrate that the striving for efficiency strongly supports the necessity to implement the core elements of Alma-Ata. Furthermore, this article analyses whether PHC has potential for the health care systems of some regions of Germany.

Methods

This paper elaborates on the basic concept of efficiency and demonstrates the relationship of PHC and health economics. Based on the example of the healthcare system in Mecklenburg-Vorpommern, a state in northeastern Germany, it is demonstrated that applying different economic approaches will result in quite different health care systems, with strong consequences for the population in this lightly populated area.

Conclusions

An efficient health care system leads to a concept that is quite similar to PHC. Thus, economic thinking is a rationale for the need to implement PHC. It can be shown that PHC was not only an appropriate approach for developing countries 30 years ago but that it is of great relevance for some regions in Germany in the new millennium.     

Work-Related Primary Care in Occupational Health Physician’s Practice

Introduction Primary care is frequently integrated in Finnish occupational health services (OHS). This study examines the frequency of work-related health problems in occupational health (OH) physicians’ consultations for primary care and associations between health problems and interventions carried out by OH physicians. Methods OH physicians assessed the health problems of 651 consecutive visits in a private OHS unit. The health problem was regarded as work-related if it was caused or aggravated by work, or involved impaired work ability. Interventions carried out by OH physicians were analysed by logistic regression analysis. Results The main health problem was caused either partially or mainly by work or symptoms were worsened by work (27%), or symptoms impaired work ability (52%). Musculoskeletal and mental disorders were the main work-related reasons for visits. In two-thirds of the cases of mental health problems, work caused or worsened symptoms, and the majority of long sickness absences were issued due to these problems. OH physicians carried out interventions concerning work or workplace in 21% of visits. Mental disorders were associated most strongly (OR 7.23, 95% CI 3.93–13.32) with interventions. The strongest association (OR 16.09, 95% CI 9.29–27.87) with work-related visits was, when the health problem was both work-induced and impaired work ability. Conclusions Work-related health problems comprise a considerable part of Finnish OH physicians’ work. OH physicians play an important role in early treatment, in the prevention of disability, and in interventions aimed at workplaces based on the knowledge they get through primary care in OHS.     

Viewpoint: „Primary Health Care“ und globale Gesundheitsinitiativen

Background

Until just a short while ago the discussion about primary health care (PHC), the concept for providing basic health care in developing countries, had all but disappeared from the academic and political international health discourse. Has PHC been definitely replaced by new initiatives or does it now have a new chance, with wide-reaching consequences for health service provision globally?

Aim

The following contribution can be seen in terms of advocacy, intended on the one hand to explain the increasingly complex aid architecture and the difficulties of integrating this into national health policy and on the other to highlight the chances and potentials that a reinvigoration of PHC could bring with it.

Results

The controversy that surrounds the PHC concept vis-à-vis selective or vertical programmes has remained more confined to ideological arguments and has often not allowed the advantages and disadvantages of both approaches to be widely explored. The millennium development goals (MDGs) include some fundamental elements of the PHC approach but have paid little attention to the PHC principles. Parallel to the efforts towards the MDGs, we are experiencing a rapid increase in the number of global health Initiatives. To reach the MDGs additional financial means are indispensable. The international foundations and global health initiatives (GHIs) have shown that high level political advocacy and an intensive media presence are necessary to mobilize considerable financial resources. However, the concern exists that resource-rich GHIs can undermine and even weaken health systems. Questions remain regarding the extent to which GHIs and their means can be directed towards a long term investment in the PHC approach and whether sustainability can be assured.     

Who Will Take Care of Us? Exploring Differences in Respondents’ Satisfaction with Primary Care vs Specialty Care Physicians

ObjectiveOur study explored perceived patient satisfaction with either primary care or specialist physicians to identify factors accounting for the differences.Study DesignThe data were collected from an Internet-based survey, DrScore.com, for measuring patient satisfaction with physicians. Participants found their doctors through the DrScore search engine and rated their physicians with anonymity. A total satisfaction score was the sum of scores based on 9 physician rating items and then was scaled to the range of 0-100. Logistic regressions were used to analyze associations between patient satisfaction (score ≥70) and various factors.ResultsThe mean satisfaction score was 79.4 for primary care (n = 11,558) and 75.5 for specialty care (n = 11,068) (P > .05). Nearly 50% of primary care patients waited for 0-2 days to get an appointment, while more than 50% of specialty care patients waited for more than 6 days. As waiting days became longer than 2 weeks, patient ratings of specialty care were lower than those of primary care. Patients (≥45 years) were 24% less likely to be satisfied with primary care (P < .01) but 40% more likely with specialty care (P < .01) than patients (<25 years).ConclusionsAlthough differences in overall patient satisfaction with primary and specialty care were not observed, more specialists obtained extremely low satisfaction scores than primary care providers did. Age and factors related to waiting time for the visit or time spent with a doctor were associated with patient satisfaction with physicians.     

Convergence or Divergence? Reforming Primary Care in Norway and Britain

Many countries are currently reorganizing their health services in response to cultural, economic, and technological changes. Because the changes are global, different countries are drawn toward similar reform programs. But countries' cultural, economic, and political differences also may lead to divergent responses. This article examines the convergence thesis by comparing recent changes in primary care in Norway and Britain. There seems to be a convergence in objectives, a divergence in remuneration systems, and both divergence and convergence in organizational structures. To understand the dynamics of change, divergence is discussed in relation to the social context of the political initiatives. Divergences are explained by economic, political, and cultural differences, as well as differences in physicians' political power and density.     

Who Should Deliver Primary Care in Long-term Care Facilities to Optimize Resident Outcomes? A Systematic Review

Objective

Across the world, health care for residents in long-term care facilities (LTCFs) is provided by a range of different professionals, and there is no consensus on which professional group(s) deliver the best outcomes for residents. The objective of this review is to investigate how the health outcomes of older adults in LTCFs vary according to which professional group(s) provides first-line medical care.

Are Adolescents Being Screened for Emotional Distress in Primary Care?

PurposeTo assess primary care providers’ rates of screening for emotional distress among adolescent patients.MethodsSecondary data analysis utilizing data from: (1) well visits in pediatric clinics within a managed care plan in California, and (2) the 2003 California Health Interview Survey (CHIS), a state population sample. The Pediatric clinic sample included 1089 adolescent patients, ages 13 to 17, who completed a survey about provider screening immediately upon exiting a well visit. The CHIS sample included 899 adolescents, ages 13 to 17, who had a routine physical exam within the past 3 months. As part of the survey, adolescents answered a question about whether they had talked with their provider about their emotions at the time of the exam. Logistic regressions, controlling for age, gender, race/ethnicity, and adolescent depressive symptoms were performed.ResultsAbout one-third of adolescents reported a discussion of emotional health. Females were significantly more likely to be screened than males (36% vs. 30% in clinic; 37% vs. 26% in CHIS); as were older and Latino adolescents in the clinic sample. Although 27% of teens endorsed emotional distress, distress was not a significant predictor of talking to a provider about emotions.ConclusionsPrimary care clinicians/systems need to better utilize the primary care visit to screen adolescents for emotional health.     

„Primary Health Care“ von Alma Ata bis Almaty

Background

With the World Health Report from October 2008 titled “Primary Health Care: Now More Than Ever”, the World Health Organization revitalised a strategy that was formulated in 1978 in Alma Ata. Only 2 days later, the alternative world health report “Global Health Watch 2” was released. This report was developed with the contributions and support of civil society participants worldwide. Despite their different perspectives, both reports critique the global prevalence of health inequities.

Aims

This article compares and illustrates the core arguments of both health reports in order to deduce implications for health promotion in Germany in a domestic and global context.

Results

In Germany, politics, science, and civil society need to play a larger role in the realisation of a comprehensive primary health care strategy. This would offer a chance to enforce the right to health and health equity for all, both in Germany and worldwide.     

Whom Should We Profile? Examining Diabetes Care Practice Variation among Primary Care Providers,Provider Groups,and Health Care Facilities

OBJECTIVE: To evaluate the amount of variation in diabetes practice patterns at the primary care provider (PCP), provider group, and facility level, and to examine the reliability of diabetes care profiles constructed using electronic databases. DATA SOURCES/STUDY SETTING: Clinical and administrative data obtained from the electronic information systems at all facilities in a Department of Veterans Affairs' (VA) integrated service network for a study period of October 1997 through September 1998. STUDY DESIGN: This is a cohort study. The key variables of interest are different types of diabetes quality indicators, including measures of technical process, intermediate outcomes, and resource use. DATA COLLECTION/EXTRACTION METHODS: A coordinated registry of patients with diabetes was constructed by integrating laboratory, pharmacy, utilization, and primary care provider data extracted from the local clinical information system used at all VA medical centers. The study sample consisted of 12,110 patients with diabetes, 258 PCPs, 42 provider groups, and 13 facilities. PRINCIPAL FINDINGS: There were large differences in the amount of practice variation across levels of care and for different types of diabetes care indicators. The greatest amount of variance tended to be attributable to the facility level. For process measures, such as whether a hemoglobin A1c was measured, the facility and PCP effects were generally comparable. However, for three resource use measures the facility effect was at least six times the size of the PCP effect, and for inter-mediate outcome indicators, such as hyperlipidemia, facility effects ranged from two to sixty times the size of the PCP level effect. A somewhat larger PCP effect was found (5 percent of the variation) when we examined a "linked" process-outcome measure linking hyperlipidemia and treatment with statins). When the PCP effect is small (i.e., 2 percent), a panel of two hundred diabetes patients is needed to construct profiles with 80 percent reliability. CONCLUSIONS: little of the variation in many currently measured diabetes care practices is attributable to PCPs and, unless panel sizes are large, PCP profiling will be inaccurate. If profiling is to improve quality, it may be best to focus on examining facility-level performance variations and on developing indicators that promote specific, high-priority clinical actions.     

Working Under a Clinic-Level Quality Incentive: Primary Care Clinicians’ Perceptions

BACKGROUND

A key consideration in designing pay-for-performance programs is determining what entity the incentive should be awarded to—individual clinicians or to groups of clinicians working in teams. Some argue that team-level incentives, in which clinicians who are part of a team receive the same incentive based on the team’s performance, are most effective; others argue for the efficacy of clinician-level incentives. This study examines primary care clinicians’ perceptions of a team-based quality incentive awarded at the clinic level.

METHODS

This research was conducted with Fairview Health Services, where 40% of the primary care compensation model was based on clinic-level quality performance. We conducted 48 in-depth interviews to explore clinicians’ perceptions of the clinic-level incentive, as well as an online survey of 150 clinicians (response rate 56%) to investigate which entity the clinicians would consider optimal to target for quality incentives.

RESULTS

Clinicians reported the strengths of the clinic-based quality incentive were quality improvement for the team and less patient “dumping,” or shifting patients with poor outcomes to other clinicians. The weaknesses were clinicians’ lack of control and colleagues riding the coattails of higher performers. There were mixed reports on the model’s impact on team dynamics. Although clinicians reported greater interaction with colleagues, some described an increase in tension. Most clinicians surveyed (73%) believed that there should be a mix of clinic and individual-level incentives to maintain collaboration and recognize individual performance.

CONCLUSION

The study highlights the important advantages and disadvantages of using incentives based upon clinic-level performance. Future research should test whether hybrid incentives that mix group and individual incentives can maintain some of the best elements of each design while mitigating the negative impacts.     

Measuring Primary Care for Children of Latino Farmworkers: Reliability and Validity of the Parent’s Perceptions of Primary Care Measure (P3C)

This study evaluates the feasibility, reliability, and validity of the Parents Perceptions of Primary Care measure (P3C) in an underserved population: children of Latino farm workers. Bilingual research assistants verbally administered the P3C, as well as a measure of child health-related quality of life (HRQL: the PedsQL 4.0) and demographic questions to 297 Latino farm worker parents of young children, in San Diego and Imperial Counties. The P3C was found to be feasible, as measured by a very low percent of missing/do not know values. Internal consistency reliability for the Total Scale and most subscales was strong. The P3Cs validity was demonstrated through factor analysis of the subscales, by showing that scores were lower for children without a regular physician and for children experiencing foregone health care, and by demonstrating that P3C scores were related to HRQL. The P3C can be useful to various stakeholders in measuring primary care for vulnerable populations.     

Does Delivering Preventive Services in Primary Care Reduce Adolescent Risky Behavior?

Purpose

To determine whether the delivery of preventive services changes adolescent behavior. This exploratory study examined the trajectory of risk behavior among adolescents receiving care in three pediatric clinics, in which a preventive services intervention was delivered during well visits.

Methods

The intervention consisted of screening and brief counseling from a provider, followed by a health educator visit. At age 14 (year 1), 904 adolescents had a risk assessment and intervention, followed by a risk assessment 1 year later at age 15 (year 2). Outcomes were changes in adolescent behavior related to seat belt and helmet use; tobacco, alcohol, and drug use; and sexual behavior. Analysis involved age-related comparisons between the intervention and several cross-sectional comparison samples from the age of 14–15 years.

Results

The change in helmet use in the intervention sample was 100% higher (p < .05), and the change in seat belt use among males was 50% higher (p = .14); the change in smoking among males was 54% lower (p < .10), in alcohol use was no different, and in drug use was 10% higher (not significant [NS]); and the change in rate of sexual intercourse was 18% and 22% lower than cohort comparison samples (NS).

Conclusions

The intervention had the strongest effect in the area of helmet use, shows promise for increasing seat belt use and reducing smoking among male adolescents, and indicates a nonsignificant trend toward delaying the onset of sexual activity. Participation in the intervention seemed to have no effect on the rates of experimentation with alcohol and drugs between the ages of 14 and 15 years.     

Linking Individuals with Substance Use Disorders (SUDs) in Primary Care to SUD Treatment: the Recovery Management Checkups–Primary Care (RMC-PC) Pilot Study

Linking individuals in primary care settings with substance use disorders (SUDs) to SUD treatment has proven to be challenging, despite the widespread use of Screening, Brief Intervention, and Referral to Treatment (SBIRT). This paper reports findings from a pilot study that examined the efficacy of the Recovery Management Checkups intervention adapted for primary care settings (RMC-PC), for assertively linking and engaging patients from Federally Qualified Health Centers into SUD treatment. Findings showed that patients in the RMC-PC (n=92) had significantly higher rates of SUD treatment entry and received more days of SUD treatment compared with those who receive the usual SBIRT referral (n=50). Receipt of RMC-PC had both direct and indirect effects, partially mediated through days of SUD treatment, on reducing days of drug use at 6 months post intake. RMC-PC is a promising intervention to address the need for more assertive methods for linking patients in primary care to SUD treatment.     

Adolescent Experiences of Clinician–Patient HIV/STI Communication in Primary Care

Effective clinician–patient communication is linked to positive patient health outcomes in adults, yet the research on adolescent populations remains limited. We describe adolescent experiences of clinician–patient HIV/STI communication through qualitative interviews with predominantly African-American adolescent women from a youth-centered primary care clinic. Participants described acknowledging clinicians are professionals, the importance of confidentiality to foster clinician–adolescent communication, and calling for clinician-initiated HIV/STI communication. Adolescents expressed the necessity for clinicians to engage youth in these challenging conversations through an open and understanding approach. Additionally, adolescents described experiences of perceived judgment and uncomfortableness from clinicians, and non-disclosure of HIV/STI risk behaviors to their clinician. Findings underscore the adolescents’ desire to engage in HIV/STI communication with healthcare providers, while highlighting important strategies for clinicians. Results can inform health communication research and practice, and the development of interventions aimed at increasing clinician–adolescent HIV/STI communication.