Patient and practitioner priorities and concerns about primary healthcare interactions for osteoarthritis: A meta-ethnography

ObjectiveTo explore primary care practitioners’ (PCPs) and patients’ priorities and concerns for healthcare interactions for osteoarthritis (OA) in primary care.MethodsWe searched Embase, CINAHL, Medline, PsychInfo (1990 to present) for primary qualitative and mixed methods studies with findings concerning healthcare interactions for OA symptoms. Patient and PCP perceptions were analysed separately then inter-related using a ‘line of argument’ synthesis.ResultsTwenty-six studies reporting qualitative data from 557 patients and 199 PCPs were synthesised. Our findings suggest that therapeutic interactions for OA can be based on discordant priorities and concerns; some patients perceive that PCPs hold negative attitudes about OA and feel their concerns about impact are not appreciated; some PCPs feel patients have misconceptions about prognosis, and hold pessimistic views about outcomes; and both tend to de-prioritise OA within consultations.ConclusionGreater working in partnership could build mutual trust, facilitate tailored provision of information, and foster a shared understanding of OA upon which to build realistic goals for management.Practice implicationsDeveloping a better shared understanding of OA has the potential to improve the quality of healthcare interactions for both patients and PCPs. The significant impact of OA on everyday life means it should be given higher priority in primary care consultations.     

A method to determine the impact of patient-centered care interventions in primary care

Objective

The implementation of patient-centered care (PCC) innovations continues to be poorly understood. We used the implementation effectiveness framework to pilot a method for measuring the impact of a PCC innovation in primary care practices.

Methods

We analyzed data from a prior study that assessed the implementation of an electronic geriatric quality-of-life (QOL) module in 3 primary care practices in central North Carolina in 2011–2012. Patients responded to the items and the subsequent patient–provider encounter was coded using the Roter Interaction Analysis System (RIAS) system. We developed an implementation effectiveness measure specific to the QOL module (i.e., frequency of usage during the encounter) using RIAS and then tested if there were differences with RIAS codes using analysis of variance.

Results

A total of 60 patient–provider encounters examined differences in the uptake of the QOL module (i.e., implementation-effectiveness measure) with the frequency of RIAS codes during the encounter (i.e., patient-centeredness measure). There was a significant association between the effectiveness measure and patient-centered RIAS codes.

Conclusion

The concept of implementation effectiveness provided a useful framework determine the impact of a PCC innovation.

Practice implications

A method that captures real-time interactions between patients and care staff over time can meaningfully evaluate PCC innovations.     

Practice size and service provision in primary care: an observational study

Background

In 2004, primary care payments for basic services and enhanced services were separated. This change has greatly facilitated the evaluation of the breadth and volume of services.

Aim

To determine whether larger practices produce a higher volume and greater diversity of enhanced services.

Design of study

Cross-sectional observational study using practice data obtained under the Freedom of Information Act 2000.

Setting

A total of 384 practices in 14 English primary care trusts.

Method

Practice data for all practices were collated for enhanced services, practice size, and deprivation. Diversity and volume of enhanced services were used as dependent variables in a series of multiple regression models to ascertain the effect of practice size, and any relationship with deprivation.

Results

Larger practices provided a greater diversity of services (P = 0.002), although this effect was not present in practices with more than 6330 patients. Practice size seems to influence the volume of enhanced services in general medical services, but this effect disappeared when deprivation was taken into account. Deprivation had a negative influence on the volume of enhanced services provided (P = 0.019). The effect of deprivation on volume persisted in practices with more than 6330 patients.

Conclusion

Current average-sized practices provide similar volume and diversity of enhanced services as those in the largest quartile; therefore, there seems to be little merit in creating ‘supersurgeries’ if the aim is to transfer work from secondary to primary care. There does not seem to be an upper threshold above which practice size creates spare capacity and expertise to deliver a significantly greater volume or more diversity of extra services.     

Enhancing delivery of health behaviour change interventions in primary care: a meta-synthesis of views and experiences of primary care nurses

Objective

To systematically find and synthesise qualitative studies that elicited views and experiences of nurses involved in the delivery of health behaviour change (HBC) interventions in primary care, with a focus on how this can inform enhanced delivery and adherence to a structured approach for HBC interventions.

Methods

Systematic search of five electronic databases and additional strategies to maximise identification of studies, appraisal of studies and use of meta-synthesis to develop an inductive and interpretative form of knowledge synthesis.

Results

Nine studies met the inclusion criteria. Synthesis resulted in the development of four inter-linking themes; (a) actively engaging nurses in the process of delivering HBC interventions, (b) clarifying roles and responsibilities of those involved, (c) engaging practice colleagues, (d) communication of aims and potential outcomes of the intervention.

Conclusion

The synthesis of qualitative evidence resulted in the development of a conceptual framework that remained true to the findings of primary studies. This framework describes factors that should be actively promoted to enhance delivery of and adherence to HBC interventions by nurses working in primary care.

Practice implications

The findings can be used to inform strategies for researchers, policymakers and healthcare providers to enhance fidelity and support delivery of HBC interventions.     

An innovative medical school curriculum to enhance exposure to genetics and genomics: Updates and outcomes

PurposeIn 2011, we introduced an innovative parallel curriculum at Baylor College of Medicine, formerly called the Genetics Track Curriculum and now called the Genetics and Genomics Pathway, aimed at providing an opportunity for an enriched educational experience throughout medical school. In this report, we describe our 10-year experience with the program and highlight growth in enrollment as well as academic achievements of graduating students.MethodsWe reviewed the data of students enrolled in this pathway, including retention, satisfaction, student-driven curriculum changes, scholarly outcomes, and career outcomes.ResultsFrom September 2011 to June 2021, 121 students were enrolled in the Genetics and Genomics Pathway program. In total, 64 students (64/121 = 53%) left the program before graduating (the majority, after their first year). Of the 57 remaining students, 29 graduated (29/57, approximately 51%), and 4 of the 29 students (4/29 = 14%) matched into a genetics training program.ConclusionThis novel program serves as a mechanism for garnering increased interest and competence in medical genetics. The longitudinal nature of the program fosters enthusiasm for genetics and provides ample opportunity to develop valuable research skills. Given the ongoing shortage of providers in this field, such programs are vital to increase the size of the workforce and broaden the knowledge of providers in diverse fields.     

Development of an electronic pictorial asthma action plan and its use in primary care

Objective

Self-management education and the issuing of a written action plan improve outcomes for asthma. Many do not receive a plan and some cannot use the written word. We have developed an electronic pictorial asthma action plan (E-PAAP).

Methods

A pictorial action plan was incorporated into a software package. 21 general practices were offered this tool and the software was loaded onto 63 desktop computers (46 GPs and 17 nurses). Usage was assessed and health care professionals questioned as to its use.

Results

190 plans had been printed in a 4-month period (17 for test purposes). The individual usage rate ranged from 0 to 28 plans. Doctors printed 73% (139/190) a mean of 3 per doctor and nurses printed 27% a mean of 2 per nurse (37/190). Excluding the test copies, 116/173(67%) were printed as picture and text together.

Conclusion

Nearly half of all healthcare professionals used the E-PAAP software. Usage was skewed with some individuals using the software significantly more than others. The software package should help overcome problems of access to paper templates, by calculating peak flow action thresholds and by prompting correct completion. Barriers to the use of asthma action plans, such as perceived time constraints, persist.

Practice implications

The development of an electronic asthma action plan facilitates health professional access to a basic template and prompts the user as to correct usage. It is to be hoped that such facilitation enhances the number of action plans issued and in this study GPs were greater users than the nurses.     

Patients' responsiveness to a decision support tool for primary prevention of cardiovascular diseases in primary care

OBJECTIVE: Assessment of patients' responsiveness to a decision support tool for primary prevention of cardiovascular diseases (CVDs). The booklet focuses on barriers at patient level. METHODS: Process evaluation of an intervention in primary care. Patients at high or potentially high-cardiovascular risk were asked by their GP to prepare themselves for a second consultation in order to participate in decisions on risk management. OUTCOMES: Patients' actually having read the booklet and returning for the second consultation; comprehension and perceived relevance of the information; perceived reassurance. RESULTS: 17 GPs, in the intervention arm of a cluster RCT, issued 276 decision support tools during the first consultation and were instructed to ask them to return for a second consultation to discuss their CVD risk. Patients had a mean age of 54 years, 47% were male and 19% actually had a high cardiovascular risk. Data on 239 patients, a mixture of returnees and non-returnees, showed that they all read the booklet; comprehension was fair to good; 85% perceived the information as relevant; 68% of the patients felt reassured by the information. Satisfaction with the first consultation was higher in the non-returnees. CONCLUSIONS: Cardiovascular prevention spread over two consultations with use of a decision support tool for patients is not easily applicable for GPs. However, based on the findings of good patients' responsiveness, we recommend further development and implementation of decision support tools in primary care. PRACTICE IMPLICATIONS: Decision support for primary CV-prevention is welcomed by patients but needs further adjustment of both the GP and the organization of CV-prevention in primary care. Sharing information between professional and patient on a personal CV-risk management plan is difficult, more training is needed.     

Rural engagement in primary care for optimizing weight reduction (REPOWER): A mixed methods study of patient perceptions

ObjectiveTo report on patients’ satisfaction and experience of care across three different modes of weight loss counseling.Methods1407 patients with obesity in the rural Midwest were enrolled to a 2-year weight management trial through their primary care practice and assigned to one of three treatment conditions: in-clinic individual, in-clinic group, phone group counseling. Patients completed surveys assessing seven domains of satisfaction and experience of care at 6 and 24-months. Post-treatment interviews were conducted to add context to survey responses.Results1295 (92.0%) and 1230 (87.4%) completed surveys at 6 and 24-months, respectively. Patients in phone group counseling reported lower satisfaction than patients who received in-clinic group or in-clinic individual counseling across all domains at 6-months and five out of seven domains at 24-months. Interviews revealed that patients were more satisfied when they received face-to-face counseling and had meaningful interactions with their primary care provider (PCP) about their weight.ConclusionRural patients with obesity have higher satisfaction and experience of care when weight loss counseling is delivered in a face-to-face environment and when their PCP is involved with their treatment.Practice implicationsPrimary care practices looking to offer weight loss treatment should consider incorporating some level of face-to-face treatment plans that involves meaningful interaction with the PCP.     

Self-management support activities in primary care: A qualitative study to compare provision across common health problems

ObjectiveTo explore the views of primary care teams about the provision of self-management support to patients with common health problems.MethodsSemi-structured interviews were conducted with twenty-one members of the primary care team from thirteen general practices. Interviews were transcribed verbatim, and analysed using the ‘Framework’ approach.ResultsThree categories and six sub-categories illustrating different self-management support activities across common health problems were identified from the analysis of interviews, and contributed to one major theme and one cross-cutting theme. Referral and signposting were frequently used to facilitate patient engagement with external services and resources. Practitioners faced some challenges in balancing medical management and psychosocial support and motivating patients to engage with self-management.ConclusionsPrimary care teams described providing a wide range of self-management support activities, but the pattern of use varied for different types of health problem. These patterns may have been influenced, in part, by general practices focusing upon achieving financially incentivised quality improvement goals.Practice implicationsTo improve self-management support, practitioners need a digital repository of services/resources, motivational interviewing skills, an understanding of the optimum duration and pattern of consultations, and incentivised targets that match a biopsychosocial model of care.     

Late-life depression in the primary care setting: Challenges,collaborative care,and prevention

Late-life depression is highly prevalent worldwide. In addition to being a debilitating illness, it is a risk factor for excess morbidity and mortality. Older adults with depression are at risk for dementia, coronary heart disease, stroke, cancer and suicide. Individuals with late-life depression often have significant medical comorbidity and, poor treatment adherence. Furthermore, psychosocial considerations such as gender, ethnicity, stigma and bereavement are necessary to understand the full context of late-life depression.     

Disease-specific education in the primary care setting increases the knowledge of people with chronic obstructive pulmonary disease: A randomized controlled trial

Objective

To examine the effect of brief disease-specific education delivered in primary care on objective measures of knowledge in individuals recently diagnosed with chronic obstructive pulmonary disease (COPD).

Methods

A randomized control trial was undertaken during which an experimental group received 2 h of education delivered by a certified COPD educator and a control group received usual care. The Bristol COPD Knowledge Questionnaire (BCKQ) was self-administered at the time of randomization and approximately three months later.

Results

Of the 93 individuals that completed the study, 50 (forced expiratory volume in 1 s [FEV₁] = 60.0 ± 14.3% predicted; 22 males) and 43 (FEV₁ = 58.2 ± 14.4% predicted; 20 males) participants were randomized to the experimental and control groups, respectively. The BCKQ increased from 27.6 ± 8.7 to 36.5 ± 7.7 points (p < 0.001) in the experimental group, which was greater than any seen in the control group (between-group difference 8.3, 95% confidence interval 5.5-11.2 points).

Conclusion

As little as 2 h of education delivered in primary care was effective at increasing objective measures of disease-specific knowledge.

Practice implications

A program of brief education delivered in the primary care setting, represents an important approach for many individuals with COPD who are unlikely to access pulmonary rehabilitation.     

Impact of integrating genomic data into the electronic health record on genetics care delivery

PurposeIntegrating genomic data into the electronic health record (EHR) is key for optimally delivering genomic medicine.MethodsThe PennChart Genomics Initiative (PGI) at the University of Pennsylvania is a multidisciplinary collaborative that has successfully linked orders and results from genetic testing laboratories with discrete genetic data in the EHR. We quantified the use of the genomic data within the EHR, performed a time study with genetic counselors, and conducted key informant interviews with PGI members to evaluate the effect of the PGI’s efforts on genetics care delivery.ResultsThe PGI has interfaced with 4 genetic testing laboratories, resulting in the creation of 420 unique computerized genetic testing orders that have been used 4073 times to date. In a time study of 96 genetic testing activities, EHR use was associated with significant reductions in time spent ordering (2 vs 8 minutes, P < .001) and managing (1 vs 5 minutes, P < .001) genetic results compared with the use of online laboratory-specific portals. In key informant interviews, multidisciplinary collaboration and institutional buy-in were identified as key ingredients for the PGI’s success.ConclusionThe PGI’s efforts to integrate genomic medicine into the EHR have substantially streamlined the delivery of genomic medicine.     

Advance care planning for cancer patients in primary care: a feasibility study

Background

Advance care planning is being promoted as a central component of end-of-life policies in many developed countries, but there is concern that professionals find its implementation challenging.

Aim

To assess the feasibility of implementing advance care planning in UK primary care.

Design of study

Mixed methods evaluation of a pilot educational intervention.

Setting

Four general practices in south-east Scotland.

Method

Interviews with 20 GPs and eight community nurses before and after a practice-based workshop; this was followed by telephone interviews with nine other GPs with a special interest in palliative care from across the UK.

Results

End-of-life care planning for patients typically starts as an urgent response to clear evidence of a short prognosis, and aims to achieve a ‘good death’. Findings suggest that there were multiple barriers to earlier planning: prognostic uncertainty; limited collaboration with secondary care; a desire to maintain hope; and resistance to any kind of ‘tick-box’ approach. Following the workshop, participants'' knowledge and skills were enhanced but there was little evidence of more proactive planning. GPs from other parts of the UK described confusion over terminology and were concerned about the difficulties of implementing inflexible, policy-driven care.

Conclusion

A clear divide was found between UK policy directives and delivery of end-of-life care in the community that educational interventions targeting primary care professionals are unlikely to address. Advance care planning has the potential to promote autonomy and shared decision making about end-of-life care, but this will require a significant shift in attitudes.