Autonomía y heteronomía,una alianza necesaria para el abordaje del tabaquismo. Visión de profesionales y pacientes

ObjectiveTo explore the perception of professionals and patients with regard to ethical issues involved in addressing the habit of smoking in primary care consultations.MethodA qualitative study was designed, consisting of 12 semi-structured interviews with professionals, 7 interviews with patients and 2 focus groups with 6 professionals and 7 primary care patients (a total of 32 participants). An intentional sampling was conducted, including profiles of professionals and patients of both sexes, different ages and experience in relation to smoking. A content analysis was performed with an inductive analytical approach from data to the creation of theoretical categories.ResultsFour main categories were identified: 1) ethical issues related to the responsibility of the professional when treating patients who smoke; 2) issues related to attitude to patients who smoke; 3) issues related to fair and equitable distribution of resources and to the role of the different levels of government in relation to the control of smoking; and 4) issues related to smokers’ autonomy regarding their habit and smoking cessation.ConclusionsAn alliance is needed between the ethics that support the autonomy of patients who smoke and the regulation of tobacco consumption. This approach should be included in clinical training programmes dealing with tobacco use, dependence and cessation.     

Healthcare professionals’ opinions,barriers and facilitators towards low-value clinical practices in the hospital setting

ObjectiveTo explore healthcare professionals’ opinions about low-value practices, identify practices of this kind possibly present in the hospital and barriers and facilitators to reduce them. Low-value practices include those with little or no clinical benefit that may harm patients or lead to a waste of resources.MethodUsing a mixed methodology, we carried out a survey and two focus groups in a tertiary hospital. In the survey, we assessed doctors’ agreement, subjective adherence and perception of usefulness of 134 recommendations to reduce low-value practices from local and international initiatives. We also identified low-value practices possibly present in the hospital. In the focus groups with professionals from surgical and medical fields, using a phenomenological approach, we identified additional low-value practices, barriers and facilitators to reduce them.Results169 doctors of 25 specialties participated (response rate: 7%-100%). Overall agreement with recommendations, subjective adherence and usefulness were 83%, 90% and 70%, respectively. Low-value practices form 22 recommendations (16%) were considered as possibly present in the hospital. In the focus groups, the professionals identified seven more. Defensive medicine and scepticism due to contradictory evidence were the main barriers. Facilitators included good leadership and coordination between professionals.ConclusionsHigh agreement with recommendations to reduce low-value practices and high perception of usefulness reflect great awareness of low-value care in the hospital. However, there are several barriers to reduce them. Interventions to reduce low-value practices should foster confidence in decision-making processes between professionals and patients and provide trusted evidence.     

Algo no estamos haciendo bien cuando informamos a los/las pacientes tras un evento adverso

ObjectiveTo analyze which actions are carried out in hospitals and primary care to ensure open disclosure to the patient after an adverse event (AE).MethodsWe surveyed 633 managers and patient safety coordinates (staff) and 1340 physicians and nurses from eight autonomous communities. The level of implementation of open disclosure recommendations was explored.ResultsA total of 112 (27.9%) staff and 386 (35.9%) professionals considered that patients were correctly informed after an EA; 30 (7.4%) staff claimed to have a guideline on how to report EA; only 92 medical professionals (17.4%) and 93 nurses (19.1%) had received training on open disclosure.ConclusionsThere are gaps in the way of planning, organizing and ensuring that patients who suffer an AE will receive an apology with honest information about what has happened and what could subsequently happen.     

Patient representatives: Crucial members of health‐care working groups facing an uncertain role and conflicting expectations. A qualitative study

BackgroundPatient representatives (PRs) have been involved for decades in health‐care development, and their participation is increasingly sought in health‐care working groups (HCWGs) on every level. However, information on how the role could be further developed and teamwork improved remains sparse.ObjectiveTo explore the role of patient representatives in clinical practice guideline (CPG) monitoring groups, to describe their contributions and identify possibilities of improvement.DesignQualitative design using semi‐structured interviews analysed by content analysis.Setting and participantsInterviews were conducted with 11 PRs, 13 registered nurses, and 9 physicians, all members of national committees monitoring CPGs for cancer in Sweden.ResultsMost participants considered the PR role important but mentioned several problems. PRs’ contributions were hampered by uncertainties about their role, the low expectations of other group members and their sense that their contributions were often disregarded. Some professionals questioned whether PRs were truly representative and said some topics could not be discussed with PRs present.ConclusionThis study highlights the fundamental problems that remain to be solved despite the long involvement of PRs in HCWGs. Even though the PR role and teamwork differed between the groups, most PRs need to be empowered to be actively involved in the teamwork and have their engagement and knowledge fully utilized. Enhancing teamwork through clarifying roles and expectations could lead to more inclusive and equal teams able to work more effectively towards the goal of improving health care.Patient or public contributionPRs were information givers in data collection.     

La participación ciudadana en la investigación desde la perspectiva de investigadores de atención primaria

ObjectiveExplore the strengths, weaknesses, opportunities and threats (SWOT) for development of public involvement in research by Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAPJGol) according to primary health care researchers in Catalonia (Spain).MethodsCross-sectional study carried out in 2017 with 36 primary health care research teams accredited by IDIAPJGol and its management staff. An open questionnaire (paper and online) was designed and piloted to develop a SWOT technique, and 65 answers were obtained (14 in paper and 51 online). A thematic content analysis was carried out.ResultsMost informants consider public involvement in research a useful, innovative, viable and essential strategy, but it requires a change of mentality and a move away from the hierarchical paradigm. It can be difficult to execute and can complicate studies. They are concerned about which citizens should be involve, how to select them, possible conflicts of interest and training needs. The main proposals for its implementation are to disseminate previous strategies, encourage motivation and synergies among citizens, researchers and institutions, and to clarify the roles of the actors involved. IDIAPJGol should develop recommendations for the public involvement in research, encourage their inclusion, have a mentor and advise the research teams.ConclusionsDespite the challenges, developing public involvement in research in primary health care is essential and feasible, what it is more should be based on a participatory strategy with all actors. The citizens can participate in any kind of design and phase of the research, adapting each project, being the primary health care a privileged area to develop the public involvement in research.     

Development,validation and transfer to clinical practice of a mobile application for the treatment of smoking

ObjectiveThe main objective is to transfer to clinical practice a new smoking cessation application (“Vive sin Tabaco” a) in all health centers of the public Basque Health Service.DesignAn implementation study of a smoking cessation program previously validated. After implementation, a retrospective study has been carried out to evaluate its use under normal conditions.SiteThe process of transfer to clinical practice has been held in several phases; first a pilotage in four health centers of Alava and subsequently, when all reported incidents were resolved, it was extended to all health centers of the Basque Health Service.Intervention and main measurementDevelopment of “Vive sin Tabaco”; a corporate tool for smoking cessation, and its transfer to clinical practice. All interested health care workers received training on how to use the application. User manuals for both patients and professionals were developed. Smoking cessation rates at 12 months during implementation were also collected.ResultsThe percentage of patients of post pilot phase who quit smoking at 12 months was 14.1%.ConclusionsThe conception of “Vive sin tabaco” as a corporate tool for smoking cessation, available in all health centers of Basque Health Service, has been long and arduous, and has required the participation of health professionals and patients as end-users in order to obtain a tool that adapts to their expectations and guarantees greater usability and satisfaction. This application is being effective as an adjuvant tool to health advice.     

The use of health care services in the Great Recession: evaluating inequalities in the Spanish context

ObjectiveTo analyse the effect of the Great Recession (2008) on primary care (PC) and secondary care (SC) inequalities in Spain.MethodRepeated cross-sectional study using Spanish Health Surveys from 2001 to 2017 (n = 139,566). Prevalence of PC and SC utilization were calculated standardized by age. Chi square tests for trend were conducted to explore the evolution. We performed logistic regression analyses adjusted by the Andersen's model of demand for care to explore inequalities prior to, during and following the recession. All the analyses were stratified by sex.ResultsHealthcare use trends changed from a rapid increase in the pre-recession period to a plateau during the recession and a decrease in the post-recession period. Healthcare use was higher in women (PC: 15.8% to 32.5%; SC: 8.2% to 16.2%) than in men (PC: 11.3% to 24.1%; SC: 5.4% to 11.6%) and the gender gap increased. During the recession the likelihood of PC use was higher in disadvantaged groups, while SC had greater usage amongst more advantaged social groups. Inequalities in SC use increased during the recession and could not be attributed to factors of need.ConclusionsHealthcare use trends changed as a result of the recession. There are socioeconomic inequalities in the use of PC and SC in Spain, which increased in secondary care, during the recession and in the post-recession period. It is necessary to take into account socioeconomic determinants in health planning, in order to achieve equity in healthcare services.     

Declaración de voluntades anticipadas: estudio cualitativo en personas mayores y médicos de Atención Primaria

ObjectivesFirst, to assess knowledge and attitudes of people aged 65 and over to the Advance Directives Document (ADD) and know the role that, in their opinion, a family doctor should play in the early planning of death. Second, to assess the level of knowledge and attitude of primary care physicians to that document, as well as to know the role played by these professionals.DesignQualitative, using discussion groups. Between March and May 2009 4 groups, 2 of physicians and 2 of older people, were formed.SettingCastile-La Mancha Primary Care Setting, Albacete and Guadalajara health areas.Subjects15 people in the groups formed by older people and 13 in the groups of doctors.MethodThe Krueger recommendations (1991) were followed both for the selection of subjects, conducting of the discussion groups and analysis of data.ResultsDoctors and patients have a positive attitude towards the ADD, but lack sufficient information to make more widespread use of it. Ignorance makes it impossible for patients to get information about the document and the lack of time makes it difficult for physicians to raise the issue in the consultation.ConclusionsNeither physicians nor the elderly have enough information regarding ADD, allowing us to recommend carrying out information campaigns and/or specific educational activities. According to physicians, alternatives to primary care consultations should be sought for patients to be informed.     

Adherence to Clinical Practice Guideline Recommendations on Low-Value Injury Care: A Multicenter Retrospective Cohort Study

ObjectivesLow-value clinical practices have been identified as one of the most important areas of excess healthcare spending. Nevertheless, there is a knowledge gap on the scale of this problem in injury care. We aimed to identify clinical practice guideline (CPG) recommendations pertaining to low-value injury care, estimate how frequently they are used in practice, and evaluate interhospital variations in their use.MethodsWe identified low-value clinical practices from internationally recognized CPGs. We conducted a retrospective cohort study using data from a Canadian trauma system (2014-2019) to calculate frequencies and assess interhospital variations.ResultsWe identified 29 low-value practices. Fourteen could be measured using trauma registry data. The 3 low-value clinical practices with the highest absolute and relative frequencies were computed tomography (CT) in adults with minor head injury (n = 5591, 24%), cervical spine CT (n = 2742, 31%), and whole-body CT in minor or single-system trauma (n = 530, 32%). We observed high interhospital variation for decompressive craniectomy in diffuse traumatic brain injury. Frequencies and interhospital variations were low for magnetic resonance imaging, intracranial pressure monitoring, inferior vena cava filter use, and surgical management of blunt abdominal injuries.ConclusionsWe observed evidence of poor adherence to CPG recommendations on low-value CT imaging and high practice variation for decompressive craniectomy. Results suggest that adherence to recommendations for the 10 other low-value practices is high. These data can be used to advance the research agenda on low-value injury care and inform the development of interventions targeting reductions in healthcare overuse in this population.     

US Physicians’ and Nurses’ Motivations,Barriers, and Recommendations for Correcting Health Misinformation on Social Media: Qualitative Interview Study

BackgroundHealth misinformation is a public health concern. Various stakeholders have called on health care professionals, such as nurses and physicians, to be more proactive in correcting health misinformation on social media. ObjectiveThis study aims to identify US physicians’ and nurses’ motivations for correcting health misinformation on social media, the barriers they face in doing so, and their recommendations for overcoming such barriers.MethodsIn-depth interviews were conducted with 30 participants, which comprised 15 (50%) registered nurses and 15 (50%) physicians. Qualitative data were analyzed by using thematic analysis.ResultsParticipants were personally (eg, personal choice) and professionally (eg, to fulfill the responsibility of a health care professional) motivated to correct health misinformation on social media. However, they also faced intrapersonal (eg, a lack of positive outcomes and time), interpersonal (eg, harassment and bullying), and institutional (eg, a lack of institutional support and social media training) barriers to correcting health misinformation on social media. To overcome these barriers, participants recommended that health care professionals should receive misinformation and social media training, including building their social media presence.ConclusionsUS physicians and nurses are willing to correct health misinformation on social media despite several barriers. Nonetheless, this study provides recommendations that can be used to overcome such barriers. Overall, the findings can be used by health authorities and organizations to guide policies and activities aimed at encouraging more health care professionals to be present on social media to counteract health misinformation.     

Barriers for identification and treatment of problem drinkers in primary care

Objective

Due to the lack of studies in the Spanish population, this study aims to analyze the barriers perceived by health professionals from different Spanish health centers when attempting to identify and treat problem drinkers and the importance given to this aspect, as well as analyzing the possible differences as a function of the professionals’ health teams. We also analyze the psychometric properties of the questionnaire used to assess these barriers.

Burden of heart failure in primary healthcare

ObjectivesTo determine the epidemiology of heart failure registered in primary healthcare clinical records in Catalunya, Spain, between 2010 and 2014, focusing on incidence, mortality, and resource utilization.DesignRetrospective observational cohort study.SettingStudy was carried out in primary care setting.Participants and interventionsPatients registered as presenting a new heart failure diagnosis. The inclusion period ran from 1st January 2010 to 31st December 2013, but patients were followed until 31st December 2013 in order to analyze mortality.Main measuresInformation came from electronic medical records.ResultsA total of 64 441 patients were registered with a new diagnosis of heart failure (2.76 new cases per 1000 persons-year). Among them, 85.8% were ≥65 years. The number of cases/1000 persons-year was higher in men in all age groups. Incidence ranged from 0.04 in women <45 years to 27.61 in the oldest group, and from 0.08 in men <45 years to 28.52 in the oldest group. Mortality occurred in 16 305 (25.3%) patients. Primary healthcare resource utilization increased after the occurrence of heart failure, especially the number of visits made by nurses to the patients’ homes.ConclusionHeart failure incidence increases with age, is greater in men, and remains stable. Mortality continues to be high in newly diagnosed patients in spite of the current improvements in treatment. Home visits represent the greatest cost for the management of this disease in primary care setting.     

Do family physicians need more payment for working better? Financial incentives in primary care

IntroductionFinancial incentives are widely used in health services to improve the quality of care or to reach some specific targets. Pay for performance systems were also introduced in the primary health care systems of many European countries.ObjectiveOur study aims to describe and compare recent existing primary care indicators and related financing in European countries.MethodsLiterature search was performed and questionnaires were sent to primary care experts of different countries within the European General Practice Research Network.ResultsTen countries have published primary care quality indicators (QI) associated with financial incentives. The number of QI varies from 1 to 134 and can modify the finances of physicians with up to 25% of their total income.ConclusionsThe implementations of these schemes should be critically evaluated with continuous monitoring at national or regional level; comparison is required between targets and their achievements, health gains and use of resources as well.     

Who is on the primary care team? Professionals’ perceptions of the conceptualization of teams and the underlying factors: a mixed-methods study

Background

Due to the growing prevalence of elderly patients with multi-morbidity living at home, there is an increasing need for primary care professionals from different disciplinary backgrounds to collaborate as primary care teams. However, it is unclear how primary care professionals conceptualize teams and what underlying factors influence their perception of being part of a team. Our research question is: What are primary care professionals’ perceptions of teams and team membership among primary care disciplines and what factors influence their perceptions?

Methods

We conducted a mixed-methods study in the Dutch primary care setting. First, a survey study of 152 professionals representing 12 primary care disciplines was conducted, focusing on their perceptions of which disciplines are part of the team and the degree of relational coordination between professionals from different disciplinary backgrounds. Subsequently, we conducted semi-structured interviews with 32 professionals representing 5 primary care disciplines to gain a deeper understanding of the underlying factors influencing their perceptions and the (mis)alignment between these perceptions.

Results

Misalignments were found between perceptions regarding which disciplines are members of the team and the relational coordination between disciplines. For example, general practitioners were viewed as part of the team by helping assistants, (district) nurses, occupational therapists and geriatric specialized practice nurses, whereas the general practitioners themselves only considered geriatric specialized practice nurses to be part of their team. Professionals perceive multidisciplinary primary care teams as having multiple inner and outer layers. Three factors influence their perception of being part of a team and acting accordingly: a) knowing the people you work with, b) the necessity for knowledge exchange and c) sharing a holistic view of caregiving.

Conclusion

Research and practice should take into account the misalignment between primary care professionals’ perceptions of primary care teams, as our study notes variations in the conceptualization of primary care teams. To enhance teamwork between professionals from different disciplinary backgrounds, professionals acknowledge the importance of three underlying conditions: team familiarity, regular and structured knowledge exchange between all professionals involved in the care process and realizing and believing in the added value for patients of working as a team.