Impact des modèles de soins intégrant l’accès direct à la kinésithérapie dans un contexte de soins primaires ou d’urgence pour les patients présentant une affection musculosquelettique : revue de la littérature

BackgroundMusculoskeletal disorders are increasing in prevalence, principally due to sedentary behaviors. Strong evidence supports an early need for first-line treatment including physiotherapy. New and innovative models in primary and emergency care have been drawn up and put the physiotherapist's skills to work in early and first-line management of patients with musculoskeletal disorders. The objectives of this review were to identify and describe studies assessing models of care integrating direct access to physiotherapy in primary care and in emergency care for patients with musculoskeletal disorders and to provide perspectives on the application of these two models in France.MethodsA literature review was carried out including studies extracted from four scientific databases: PubMed, CINAHL, Embase, and PEDro. The selected articles had to address the clinical effectiveness or efficiency of these models for the provision of care in primary or in emergency care. A narrative literature review method was used. The synthesis deals with the qualitative analysis of the included studies.ResultsThirty-nine studies were included in this review: 19 on assessment of the direct access to physiotherapy model in primary care and 20 on the direct access to physiotherapy model in emergency departments as concerns patients with musculoskeletal disorders. The studies showed that the different models incorporating direct access to physiotherapy in primary or in emergency care provided better outcomes in terms of quality and access to care while maintaning a similar degree of safety. However, the methodology of the studies included was estimated as being of heterogeneous quality.ConclusionThe studies dealing with the new models for provision of care integrating direct access to physiotherapy in primary care or emergency care impart two lessons: (1) they are not designed to replace the physician; (2) collaboration between different health professionals aimed at improving patients’ access to efficient care is to be encouraged. It would be worthwhile to focus upon dissemination factors that would enhance the efficiency of these innovative models in other countries, as in France.     

Loss of doctor-to-doctor communication: lessons from the reconfiguration of mental health services in England

OBJECTIVE: To explore the tensions across the primary-secondary interface when referral from primary care is to a team and to inform service developments in other specialties. METHODS: A nested qualitative study within a randomized controlled trial of primary care and Community Mental Health Teams (CMHTs) in Croydon and Manchester, UK. For the qualitative study, interviews were carried out with general practitioners (GPs), psychiatrists and managers or clinical leads of the CMHTs. RESULTS: GPs described the need for access to specialist knowledge, which they perceived to lie with the psychiatrist, and referral to a team was not perceived to allow this access. A personal threshold was identified by GPs after which they referred the patient to secondary care. CMHTs and psychiatrists recognized that this personal threshold differed between GPs, but their criteria for accepting referrals did not seem to allow for a flexible response to referral requests, leading to the referral being labelled as 'inappropriate'. The lack of direct doctor-to-doctor communication was perceived by respondents to contribute to a fragmentation of patient care. Strategies were described whereby the system was bypassed to achieve doctor-to-doctor communication, which undermined the team. CONCLUSIONS: Development of intermediate or 'Tier 2' services beyond the mental health services, where the GP refers to a team rather than to a specialist (hospital consultant) could benefit from reflecting on experiences with mental health services. There is a danger that new community services for the physically ill will engender the same level of confusion and discontent described by GPs and other health professionals in this study who are concerned with mental health care. Flexibility is needed within care pathways, including the provision of direct doctor-to-doctor communication together with approaches to minimize the marginalization of non-medical professionals.     

Access to health care in nursing homes: a survey in one English Health Authority

The objective of the study was to establish the arrangements for provision of general practitioner (GP), nursing advice, chiropody, physiotherapy and speech and language services to nursing homes and to establish the charging policies for those services. To this end a telephone survey of the managers of the 51 nursing homes registered with one English health authority, Merton, Sutton and Wandsworth Health Authority, was undertaken. Forty-nine homes (96%) with 1541 residents responded. Twenty per cent of homes had no regular GP visits and half the homes had no planned medication reviews. One in five homes (27% of residents) had access to all health-care services. Eight homes (10% of residents) did not have access to therapy services or nursing advice. Thirty-three homes used private or both private and NHS chiropody services and 16 homes used the NHS service only. Seventeen homes used private or both private and NHS physiotherapy services with 10 homes receiving a regular private service. Twenty homes used the NHS service and 12 homes (15% of residents) had used no physiotherapy service. None used private speech and language services. Twenty-four of the 33 homes using private chiropody charged extra for this service compared with two of 10 homes using regular private physiotherapy. The findings suggest that there are inequalities in access to health care services in nursing homes. Moreover, there has been a deterioration in access to and levels of provision of NHS nursing and physiotherapy services since the national survey undertaken by the Office Population Censuses and Surveys (OPCS) in Great Britain in the mid-1980s. The new regulatory framework for older people must include systems for monitoring the provision of health services.     

Are general practitioner hospitals cost-saving? Evidence from a rural area of Norway

OBJECTIVE: We aimed to determine whether general practitioner GP hospitals, compared with alternative modes of health care, are cost- saving. METHODS: Based on a study of admissions (n = 415) to fifteen GP hospitals in the Finnmark county of Norway during 8 weeks in 1992, a full 1-year patient throughput in GP hospitals was estimated. The alternative modes of care (general hospital, nursing home or home care) were based on assessments by the GPs handling the individual patients. The funds transferred to finance GP hospitals were taken as the cost of GP hospitals, while the cost of alternative care was based on municipality and hospital accounts, and standard charges for patient transport. RESULTS: The estimated total annual operating cost of GP hospitals was 32.2 million NOK (10 NOK = 1 Pound) while the cost of alternative care was in total 35.9 million NOK. Sensitivity analyses, under a range of assumptions, indicate that GP care in hospitals incurs the lowest costs to society. CONCLUSION: GP hospitals are likely to provide health care at lower costs than alternative modes of care.      

Treatment of diabetes mellitus type 2 in family practice

In the care of type 2 diabetes mellitus, a combined approach is required to address the risk factors for micro- and macrovascular complications. In the Netherlands, type 2 diabetes care is mainly provided by the general practitioner (GP). GP care is often not provided in accordance with the guidelines, and the strict targets for glycaemic, blood pressure and lipid control are often not achieved. Therefore, the GP should be supported in the provision of diabetes care. GP support in providing diabetes care can range from the organisation of care within the individual GP practice, through to support from an organisation within primary care or to 'shared care' with a hospital in secondary care. There is still scarce scientific evidence for the effectiveness of models for the organisation of diabetes care in primary care in the Netherlands. Scientific research into the effectiveness and cost-effectiveness is necessary before models for the organisation of diabetes care in primary care can be widely implemented and structurally financed.     

The globalization of emergency medicine and its importance for public health

Emergency medicine (EM) is a global discipline that provides secondary disease prevention and is also a tool for primary prevention. It is a horizontally integrated system of emergency care consisting of access to EM care; provision of EM care in the community and during transportation of patients; and provision of care at the receiving facility or hospital emergency department. EM can offer many tools to improve public health. These tools include primary disease prevention; interventions for addressing substance abuse and interpersonal violence; education about safety practices; epidemiological surveillance; enrolment of patients in clinical research trials focusing on acute interventions; education and clinical training of health-care providers; and participation in local and regional responses to natural and man-made disasters. Public health advocates and health policy-makers can benefit from the opportunities of EM and can help overcome its challenges. Advocating the establishment and recognition of the specialty of EM worldwide can result in benefits for health-care education, help in incorporating the full scope of EM care into the system of public health, and expand the capabilities of EM for primary and secondary prevention for the benefit of the health of the public.     

Accessibility and spatial distribution of general practice services in an Australian city by levels of social disadvantage

The accessibility and spatial distribution of health services provided by the main source of primary medical care in Australia--the general practice surgery--was investigated by level of social disadvantage of local catchment areas. All 459 general practice surgeries in Perth, an Australian city of 1.2 million residents, were surveyed with a 94% response. Amount of service provision was measured using weekly doctor-hours, available from consulting rooms during opening hours, and associated nurse-hours of service. Access factors were defined as the distance to the nearest surgery, provision of Sunday and evening services, ease of making a same day appointment, bulk-billing, and whether the surgery offered a choice of gender of doctor. There were relatively more surgeries in disadvantaged areas and doctor-hours of service provision were also greater (41.0 h/1,000 most disadvantaged vs. 37.9 h/1000 least disadvantaged). Bulk-billing care, at no direct cost to the patient, was more likely to be provided in most disadvantaged areas compared with least disadvantaged areas (61 vs. 38%). However, populations living in the most disadvantaged areas were less likely to be able to see the local GP at short notice (91 vs. 95%), to have access to a local female GP (56 vs. 62%) or a local service in the evenings (42 vs. 51%). While the overall picture of accessibility was favourable, there was considerable variation in the type of services provided to different socioeconomic groups. Health care planners should investigate the reasons for these differences and advise Government to ensure that access factors affecting publicly funded services are equitably distributed.     

Impact of rural hospital closures in Saskatchewan, Canada

Canada's health care system has undergone major changes since 1990. In Saskatchewan, 52 small rural hospitals funded for less than eight beds stopped receiving funding for acute care services in 1993. Most were subsequently converted to primary health care centers. Since then, concerns have been raised about the impact of the changes on rural residents' access to care, their health status, and the viability of rural communities. To assess the impact of hospital closures on the affected communities, we conducted a multi-faceted, province-wide study. We looked at hospital use patterns, health status, rural residents' perceptions of the impact of these hospital closures, and how communities responded to the changes. We found the hospital closures did not adversely affect rural residents' health status or their access to inpatient hospital services. Despite widespread fears that health status would decline, residents in these communities reported that hospital closures did not adversely affect their own health. Although some communities continue to struggle with changes to health care delivery, others appear to have adapted as a result of strong community leadership, the development of widely accepted alternative services, and local support for creating innovative solutions. Good rural health care does not depend on the presence of a very small hospital that cannot, in today's environment, provide genuinely acute care. It requires creative approaches to the provision of primary care, good emergency services, and good communication with the public on the intent and outcomes of change.     

Clinical management. Where medicine meets management. Muscle power

Physiotherapy-led services can dramatically cut orthopaedic waiting times, improve patient choice and reduce GP workload. Waiting times are cut by reducing the number of unnecessary referrals. Providing more direct access to physiotherapy services is key.     

Effects of access to radiology in out-of-hours primary care on patient satisfaction and length of stay

BackgroundDirect access to hospital radiology facilities by general practitioner (GP) cooperatives is known to decrease the number of emergency department referrals, but the effects on length of stay (LOS; time from patient arrival at GP cooperative till departure to home) and patient experiences are unclear.ObjectivesTo provide insight into the LOS and experiences of trauma patients with an indication for radiology at GP cooperatives with and without access to radiology.MethodsA multi-methods observational study in April 2014–October 2015 at six GP cooperatives in The Netherlands, covering three organisational models for access to radiology: no direct access, limited access and unlimited access. Patient experiences were measured with a questionnaire. Patient records were analysed for background characteristics, radiology outcomes, referral and LOS.ResultsIn total 657 patients were included, 232 no direct access model, 307 limited access model and 118 unlimited access model. The mean LOS was 99 minutes, with a significant difference between GP cooperatives without access to radiology (121 minutes), with limited access (86 minutes), and with unlimited access (90 minutes). The differences were larger for patients without radiological abnormalities. On a ten-point scale, patients rated GP cooperatives with unlimited access to radiology higher (8.62) than those without access (8.36) or with limited access (8.39).ConclusionAccess to radiology by GP cooperatives seems to reduce the length of stay and is slightly more appreciated by patients. GP cooperatives with unlimited access seem to provide the most efficient and best-valued care, contributing to more patient-centred care.     

Voluntary or compulsory health care reform? The case of primary care organisations in Scotland

Previous studies have suggested that voluntary reform of the delivery of primary care services is more likely to occur in affluent areas. Health system reforms that include voluntary participation of GPs may therefore lead to a two-tier service in terms of access to and utilisation of medical services. New primary care organisations in Scotland (local health care co-operatives) were introduced in 1999. These are groups of general practices and membership was voluntary. The aim of this study is to examine whether the voluntary nature of membership was likely to exacerbate or reduce inequalities in the provision of primary care services. Logistic regression analysis was used to identify differences in population, practice, and GP characteristics between general practices that have joined a co-operative and those that have not. The results indicated that practices located in deprived areas and covering populations with high levels of morbidity were more likely to join a co-operative. High workload decreased the probability of membership. General practices that found it difficult to obtain access to local authority residential care homes were more likely to join a co-operative. The number of fee claims for minor surgery sessions per whole-time equivalent GP increased the probability of membership. There is therefore some evidence indicating that general practices located in areas of high need are more likely to join a co-operative. This suggests that voluntary participation in these new primary care organisations may reduce rather than exacerbate inequalities in the provision of primary care.     

Impact on and use of health services by international migrants: questionnaire survey of inner City London A&E attenders

Background  

Changing immigration trends pose new challenges for the UK's open access health service and there is considerable speculation that migrants from resource-poor countries place a disproportionate burden on services. Data are needed to inform provision of services to migrant groups and to ensure their access to appropriate health care. We compared sociodemographic characteristics and impact of migrant groups and UK-born patients presenting to a hospital A&E/Walk-In Centre and prior use of community-based General Practitioner (GP) services.     

Across the health-social care divide: elderly people as active users of health care and social care

Several ways in which elderly people may assume an active role when using welfare services are discussed here. Selected findings are presented from a study that explored the experience and behaviour of elderly people on discharge from inpatient care with regard to criteria indicating user influence or control (namely participation, representation, access, choice, information and redress). Data were collected via semistructured interviews with service users (n = 30) soon after their return home from hospital. A number of differences were revealed between health care and social care in relation to users being provided with opportunities to assume an active role and in being willing and able to assume an active role. These differences were manifest in elderly service users accessing services, seeking information, exercising choice and acting independently of service providers. It appeared paradoxical that contact points were more easily defined with regard to health care yet users were more likely to exercise choice and act independently in securing social care. It is suggested that social care needs and appropriate service delivery are more easily recognised than making the link between perceived health care needs and appropriate services. In addition, it appeared that informal and private providers are more widely available and accessible for social care. If comprehensive continuing care is to be provided, incorporating both health and social care elements, greater uniformity appears to be required across the welfare sector. Lessons for social care provision from the delivery of health care suggest the clear definition of contact points to facilitate service use. Making health care more accessible, however, does not appear to be easily attainable due to the monopoly provision of health care and the lack of direct purchasing power by potential users.     

The impact of team-based primary care on health care services utilization and costs: Quebec’s family medicine groups

We investigate the effects on health care costs and utilization of team-based primary care delivery: Quebec’s Family Medicine Groups (FMGs). FMGs include extended hours, patient enrolment and multidisciplinary teams, but they maintain the same remuneration scheme (fee-for-service) as outside FMGs. In contrast to previous studies, we examine the impacts of organizational changes in primary care settings in the absence of changes to provider payment and outside integrated care systems. We built a panel of administrative data of the population of elderly and chronically ill patients, characterizing all individuals as FMG enrollees or not. Participation in FMGs is voluntary and we address potential selection bias by matching on GP propensity scores, using inverse probability of treatment weights at the patient level, and then estimating difference-in-differences models. We also use appropriate modelling strategies to account for the distributions of health care cost and utilization data. We find that FMGs significantly decrease patients’ health care services utilization and costs in outpatient settings relative to patients not in FMGs. The number of primary care visits decreased by 11% per patient per year among FMG enrolees and specialist visits declined by 6%. The declines in costs were of roughly equal magnitude. We found no evidence of an effect on hospitalizations, their associated costs, or the costs of ED visits. These results provide support for the idea that primary care organizational reforms can have impacts on the health care system in the absence of changes to physician payment mechanisms. The extent to which the decline in GP visits represents substitution with other primary care providers warrants further investigation.     

Do patients want to disclose psychological problems to GPs?

BACKGROUND: GPs are an accessible health care provider for most patients with mental disorders and are gatekeepers to specialist care. The extent to which patients consider their primary care team as relevant to their mental health problems needs to be explored. OBJECTIVES: To explore reasons why patients choose not to disclose psychological problems to GPs, and to discuss the implications for the provision of primary mental health care. METHODS: A cross-sectional survey of consecutive patients attending general practices in New Zealand (part of the MaGPIe study). Patients were screened using the GHQ-12 and a stratified sample participated in a structured in-depth interview to assess their psychological health. Non-disclosure of psychological problems was explored. GPs assessed patients' psychological health using a 5-point scale of severity. RESULTS: Seventy GPs (90%) and 775 patients (70%) participated. Overall, 29.8% of all patients and 36.9% of patients with current symptoms reported non-disclosure of self-perceived psychological problems. Younger patients, those consulting more frequently and those with greater psychiatric disability were more likely to report non-disclosure. The most frequently given reasons were beliefs that a GP is not the 'right' person to talk to (33.8%) or that mental health problems should not be discussed at all (27.6%). CONCLUSIONS: Interventions such as screening and GP education may be ineffective in improving primary mental health care unless accompanied by educational programmes for the general public to increase mental health literacy, de-stigmatise mental illness and increase awareness of general practice as an appropriate and effective source of health care.     

Integration of medical and psychological treatment within the primary health care setting

Integrated care entails the provision of behavioral health services within the primary care setting and emphasizes a collaborative approach between mental health professionals and primary care providers (Kenkel, Deleon, Orabona Mantell, Steep, 2005). Research was collected to highlight the history, development, and implementation of integrated care within primary care facilities. The authors performed a comprehensive literature review of collaborative care and summarized the program design of the site where they work. It is hypothesized that integration will improve patient access to health care, increase the rate of evidence based practice, improve patient health and satisfaction, and reduce long-term costs.     

The 1990 GP contract--meeting needs?

This paper reviews the empirical evidence about the effects of the 1990 general practitioner (GP) contract on the provision of medical services in the United Kingdom. A brief outline of the major changes instigated by the 1990 GP contract is given. Studies of the implementation of the changes tend to focus on either trend analysis, cost-effectiveness or medical practice variation. These studies are reviewed and the implications for the efficiency of primary health care are discussed.     

Measuring concentration in primary care

There is evidence that patient choice and the quality of service delivery in primary care can be influenced by the organisation and structure of provision at the local level. However, the formal measurement of structure in primary care has yet to be undertaken. Using data for Coventry, standard concentration measures are estimated, which show that concentration varies considerably across the city and tends to be higher in areas of lower deprivation. Assuming that patient choice is an important consideration in health care planning, concentration measurement may provide a useful tool for health authorities in making decisions about GP numbers, practice mergers and re‐location. This revised version was published online in July 2006 with corrections to the Cover Date.     

Can increased primary care access reduce demand for emergency care? Evidence from England's 7-day GP opening

Restricted access to primary care can lead to avoidable, excessive use of expensive emergency care. Since 2013, partly to alleviate overcrowding at the Accident & Emergency (A&E) units of hospitals, the UK has been piloting 7-day opening of General Practitioner (GP) practices to improve primary care access for patients. We evaluate the impact of these pilots on patient attendances at A&E. We estimate that 7-day GP opening has reduced A&E attendances by patients of pilot practices by 9.9% with most of the impact on weekends which see A&E attendances fall by 17.9%. The effect is non-monotonic in case severity with most of the fall occurring in cases of moderate severity. An additional finding is that there is also a 9.9% fall in weekend hospital admissions (from A&E) which is entirely driven by a fall in admissions of elderly patients. The impact on A&E attendances appears to be bigger among wealthier patients. We present evidence in support of a causal interpretation of our results and discuss policy implications.     

IMPROVING EQUITY AND EFFICIENCY IN THE BUSH: A NEEDS-BASED METHOD FOR HEALTHCARE RESOURCE ALLOCATION IN REMOTE COMMUNITIES

ABSTRACT: Outback Australia still exists as a frontier economy, relying on public sector provision of the vast majority of services, including health care. In the Northern Territory (NT), high mortality ratios and hospitalisation rates reflect the poor health status of Aborigines who, in 1990-91, accounted for 25% of the population but 40% of hospital patients and 53% of hospital bed days. Funding for primary health care continues to be based on historical utilisation rates, which perpetuates the existing bias towards the urban hospital sector. Health care expenditure analysis suggests that current expenditure patterns fail to fulfil national goals of equity of access and allocation efficiency (maximisation of health outcomes) for the NT Aboriginal population.
This paper outlines a population needs-based resource allocation formula for remote communities, which takes account of three factors: mortality, cost of remoteness and demographic structure. National per capita health care utilisation data are used as a baseline and an allocation weighting is proposed based on the above three factors. This formula is then applied to a typical remote central Australian community. The cost-benefit implications of this alternative funding strategy are explored.