Does practice size matter? Review of effects on quality of care in primary care

Background

There is a trend towards consolidating smaller primary care practices into larger practices worldwide. However, the effects of practice size on quality of care remain unclear.

Aim

This review aims to systematically appraise the effects of practice size on the quality of care in primary care.

Design and setting

A systematic review and narrative synthesis of studies examining the relationship between practice size and quality of care in primary care.

Method

Quantitative studies that focused on primary care practices or practitioners were identified through PubMed, CINAHL, Embase, Cochrane Library, CRD databases, ProQuest dissertations and theses, conference proceedings, and MedNar databases, as well as the reference lists of included studies. Independent variables were team or list size; outcome variables were measures of clinical processes, clinical outcomes, or patient-reported outcomes. A narrative synthesis of the results was conducted.

Results

The database search yielded 371 articles, of which 34 underwent quality assessment, and 17 articles (13 cross-sectional studies) were included. Ten studies examined the association of practice size and clinical processes, but only five found associations of larger practices with selected process measures such as higher specialist referral rates, better adherence to guidelines, higher mammography rates, and better monitoring of haemoglobin A1c. There were mixed results for cytology and pneumococcal coverage. Only one of two studies on clinical outcomes found an effect of larger practices on lower random haemoglobin A1 value. Of the three studies on patient-reported outcomes, smaller practices were consistently found to be associated with satisfaction with access, but evidence was inconsistent for other patient-reported outcomes evaluated.

Conclusion

There is limited evidence to support an association between practice size and quality of care in primary care.     

Does the evidence referenced in NICE guidelines reflect a primary care population?

Background

Guidelines are a common and important tool in providing high-quality health care. The National Institute for Health and Clinical Excellence (NICE) guidelines are now being used to set standards for assessing the quality of care in UK general practice, and so the evidence behind them needs to be relevant to primary care.

Aim

To assess the extent to which guideline recommendations aimed at primary care are based on research conducted in a primary care setting.

Design of study

Purposeful selection of a sample of NICE guidelines for conditions commonly seen in general practice, with identification of the evidence underpinning recommendations that are relevant to primary care.

Method

Three recent NICE guidelines were selected: chronic obstructive pulmonary disease (COPD), hypertension, and respiratory tract infection in adults and children. Publications referenced as evidence for each individual primary care relevant recommendation were classified as to whether or not they were based in primary care relevant settings.

Results

In the three guidelines assessed, 160 studies were used to derive the 115 recommendations that were relevant to, or aimed at primary care. A wide variation was found in the proportion of studies that recruited patients from a setting relevant to primary care (range 26% to 80%).

Conclusion

In this sample of three NICE guidelines, a significant proportion of studies underlying the primary care relevant recommendations were derived from studies that were not conducted in that setting. In producing guidelines for a primary care audience, the guideline development groups should include explicit information about the setting of studies underpinning the recommendations.     

Randomized controlled trial of SystemCHANGE™ weight management intervention in neurological conditions

ObjectiveThis randomized controlled pilot study examined the feasibility and efficacy of a SystemCHANGE™ (SC) weight management intervention in adults with either multiple sclerosis or stroke.MethodsParticipants (n = 61) were randomized into two interventions: SC, which taught skills to modify personal environments, or active-control (AC), which taught health behavior guidelines. Sessions were held weekly for 12 weeks. Feasibility measures included recruitment and attrition rates. The primary outcome of body weight and secondary outcomes of emotional well-being and healthy behaviors were measured before and after the interventions.ResultsAverage recruitment rate was 3.6 participants per month. Attrition rate was 14.8%. On average, 9.1 sessions were completed for SC and 10.7 for AC. Differences in weight loss were non-significant between interventions (P = 0.182), but significantly declined across both interventions (P = 0.011). Physical activity (P = 0.002), depression (P < 0.001), anxiety (P = 0.023), and self-efficacy (P = 0.022) all significantly improved for SC compared to AC.ConclusionsSC was feasible to implement and efficacious in improving secondary outcomes of emotional well-being and healthy behaviors, but was not efficacious in improving the primary outcome of weight loss. More research is needed to optimize SC.Practice implicationsSC might be an alternative approach to cognitive-behavioral therapy for promoting emotional well-being and healthy behaviors.     

Does patient education modify behaviour in the management of COPD?

With respect to the beneficial health effects of patient education in the treatment of asthma it might be expected that the active participation of COPD-patients in the management of their disease may reduce the burden of the disease. Self-management of chronic obstructive pulmonary disease (COPD) includes sufficient coping behaviour, compliance with inhaled medication, attention to changes in the severity of the disease, adequate inhalation technique, and self-adjustment of the medication in case of exacerbations. In contrast to the conflicting results of the current literature, the evaluation of our structured education programme for patients with mild to moderate COPD revealed a significant improvement of inhalation technique and self-control of the disease as well as a significant reduction of exacerbations. Therefore, it may be concluded that education may modify the behaviour of patients in the management of COPD by improving self-control and self-management of the disease and thus reducing morbidity.     

Perceived discrimination in primary care: Does Payer mix matter?

IntroductionPrevious literature has explored patient perceptions of discrimination by race and insurance status, but little is known about whether the payer mix of the primary care clinic (i.e., that is majority public insurance vs. majority private insurance clinics) influences patient perceptions of race- or insurance-based discrimination.MethodsBetween 2015-2017, we assessed patient satisfaction and perceived race- and insurance-based discrimination using a brief, anonymous post-clinic visit survey.ResultsParticipants included 3,721 patients from seven primary care clinics—three public clinics and four private clinics. Results from unadjusted logistic regression models suggest higher overall reports of race- and insurance-based discrimination in public clinics compared with private clinics. In mulvariate analyses, increasing age, Black race, lower education and Medicaid insurance were associated with higher odds of reporting race- and insurance-based discrimination in both public and private settings.ConclusionReports of race and insurance discrimination are higher in public clinics than private clinics. Sociodemographic variables, such as age, Black race, education level, and type of insurance also influence reports of race- and insurance-based discrimination in primary care.     

Does pay-for-performance influence the quality of care?

PURPOSE OF REVIEW: To summarize studies of pay-for-performance programmes designed to address clinical quality of care markers in ambulatory settings at the level of the physician group or individual physician. RECENT FINDINGS: Seven randomized controlled trials and 15 nonrandomized studies were reviewed. Less than half of the randomized controlled trials showed positive results, whereas all but one of the nonrandomized studies showed positive or mixed results. Characteristics of the quality measures, incentives, providers, patients, and concurrent interventions probably influenced the results. Study methodology problems such as small sample sizes, selection bias, and inadequate control for confounders were common. Asthma quality of care markers were included in three nonrandomized studies, two of which showed positive results and one of which was negative. SUMMARY: The data reviewed in this article suggest that pay-for-performance programmes can improve markers of quality, though not always. Even when studies suggest positive effects, the designs often do not permit assurance that the effects are due to the incentives as compared with other factors. More and better-designed studies are needed to determine the actual effectiveness of incentives themselves isolated from other factors, circumstances that promote effectiveness, effectiveness relative to other strategies, and cost-effectiveness.     

Does the cell-brain theory work in explaining carcinogenesis?

As a major microtubule-organizing center, the centrosome, together with the embedded centrioles and connecting filaments (or microtubules), has lately been proposed to be the "brain" of a cell. Although there are a lot of works to be done to test this hypothesis, emerging data have suggested that this centrosome-centered "cell brain" is playing increasingly important roles in cell control. Genes seem not to tell the whole story, despite the commonly held view that genetic alteration is the cause of most medical problems including cancer development. Although the mechanisms through which gene expression and protein synthesis are regulated remain to be studied, current advances in our understanding of the roles of the centrosome in the regulation of DNA synthesis, DNA repair, cell cycle, apoptosis and in the maintenance of genetic stability are challenging our tradition thoughts. Genetic alterations may be repaired by the centrosome-centered "cell brain"-mediated self-defense, but the cell brain defects intend to cause genetic alterations, which, in turn, may result in cancer development. Further understanding of the roles of the centrosome/cell brain in these and other new aspects are becoming very helpful in comprehending why and how medical problems including tumors develop. Meanwhile, it suggests that great attention should be given to the centrosome/cell brain, instead of gene alone when treating medical problems, which is discussed in this paper on the basis of cell brain theory and may prove helpful in shedding light on the often paradoxical observations seen in cell control, particularly in cancer development.     

Childhood long-term conditions in primary care: a qualitative study of practitioners’ views

Background

Improving child health and wellbeing in England was the key focus of the Chief Medical Officer’s Annual Report 2012, which recommended that all children with long-term conditions (LTCs) have a named GP responsible for their care. Little is known, however, about practitioners’ views and experiences of supporting children with LTCs in primary care.

Aim

To explore practitioners’ views of supporting children with LTCs and their families in primary care.

Design and setting

Qualitative interview study in primary care settings in South Yorkshire, England.

Method

Interviews explored practitioners’ views and experiences of supporting children with asthma, cystic fibrosis, type 1 diabetes, and epilepsy. Interviews were audiotaped, transcribed verbatim, and analysed using the framework approach.

Results

Nineteen practitioners were interviewed: 10 GPs, five practice nurses, and four nurse practitioners. The GPs’ clinical roles included prescribing and concurrent illness management; nurse practitioners held minor illness clinics; and practice nurses conduct asthma clinics and administer immunisations. GPs were coordinators of care and provided a holistic service to the family. GPs were often unsure of their role with children with LTCs, and did not feel they had overall responsibility for these patients. Confidence was dependent on experience; however, knowledge of GPs’ own limits and accessing help were felt to be more important than knowledge of the condition.

Conclusion

Primary care has a valuable role in the care of children with LTCs and their families. This study suggests that improving communication between services would clarify roles and help improve the confidence of primary care practitioners.     

Does health coaching change patients’ trust in their primary care provider?

Objective

To assess the impact of health coaching on patients’ in their primary care provider.

Methods

Randomized controlled trial comparing health coaching with usual care.

Participants

Low-income English or Spanish speaking patients age 18–75 with poorly controlled type 2 diabetes, hypertension and/or hyperlipidemia.

Main outcome measure

Patient trust in their primary care provider measured by the 11-item Trust in Physician Scale, converted to a 0–100 scale.

Analysis

Linear mixed modeling.

Results

A total of 441 patients were randomized to receive 12 months of health coaching (n = 224) vs. usual care (n = 217). At baseline, the two groups were similar to those in the usual care group with respect to demographic characteristics and levels of trust in their provider. After 12 months, the mean trust level had increased more in patients receiving health coaching (3.9 vs. 1.5, p = 0.47), this difference remained significant after adjustment for number of visits to primary care providers (adjusted p = .03).

Conclusions

Health coaching appears to increase patients trust in their primary care providers.

Practice Implications

Primary care providers should consider adding health coaches to their team as a way to enhance their relationship with their patients.     

Does the achievement of medical identity limit the ability of primary care practitioners to be patient-centred?: A qualitative study

OBJECTIVE: To explore primary care practitioners approach to and management of menstrual disorders using a sociological perspective. METHODS: Semi-structured interviews of primary care practitioners with an iterative approach to recruitment and analysis informed by grounded theory. RESULTS: Two broad approaches to patient care were described-a biomedical approach, which concentrated on medical history taking and the search for disease, and a patient-as-person approach where a patient's individual ideas and concerns were elicited. Practitioners believed they had a role in integrating these approaches. Activities intrinsic to the biomedical approach such as the performance of examinations, the ordering of tests and making decisions about biomedical aspects of care were however not available for shared decision-making. The exercise of these decisions by medical practitioners was necessary for them to achieve their professional identity. CONCLUSION: While practitioners accepted the ideology of patient-centred care the biomedical approach had the advantage of providing practitioners with a professional identity, which protected their status in relation to patients and colleagues. PRACTICE IMPLICATIONS: The adoption of shared decision-making by medically qualified primary care practitioners is limited by practitioners need to achieve their medical identity. At present, this identity does not involve significant sharing of power and responsibility. A shift in perception of medical identity is required before more shared decision-making is seen in practice.     

Long-term results after primary augmented repair of proximal tears of the anterior cruciate ligament with the Kennedy-LAD — Does it work?

Background

The purpose of this study was to objectively evaluate the clinical functionality of the knee joint 30?years after surgical augmentation of the ACL with the “Kennedy Ligament Augmentation Device ®” (Kennedy LAD®).

Is the international normalised ratio (INR) reliable? A trial of comparative measurements in hospital laboratory and primary care settings.

AIM: To determine the reliability of international normalised ratio (INR) measurement in primary care by practice nurses using near patient testing (NPT), in comparison with results obtained within hospital laboratories by varied methods. METHODS: As part of an MRC funded study into primary care oral anticoagulation management, INR measurements obtained in general practice were validated against values on the same samples obtained in hospital laboratories. A prospective comparative trial was undertaken between three hospital laboratories and nine general practices. All patients attending general practice based anticoagulant clinics had parallel INR estimations performed in general practice and in a hospital laboratory. RESULTS: 405 tests were performed. Comparison between results obtained in the practices and those in the reference hospital laboratory (gold standard), which used the same method of testing for INR, showed a correlation coefficient of 0.96. Correlation coefficients comparing the results with the various standard laboratory techniques ranged from 0.86 to 0.92. It was estimated that up to 53% of tests would have resulted in clinically significant differences (change in warfarin dose) depending upon the site and method of testing. The practice derived results showed a positive bias ranging from 0.28 to 1.55, depending upon the site and method of testing. CONCLUSIONS: No technical problems associated with INR testing within primary care were uncovered. Discrepant INR results are as problematic in hospital settings as they are in primary care. These data highlight the failings of the INR to standardise when different techniques and reagents are used, an issue which needs to be resolved. For primary care to become more involved in therapeutic oral anticoagulation monitoring, close links are needed between hospital laboratories and practices, particularly with regard to training and quality assurance.     

Does diclofenac increase the risk of cervical necrotizing fasciitis in a rat model?

Non-steroidal anti-inflammatory drugs (NSAIDs) are known for aggravating in vitro infections and were reported in many cases of cervical necrotizing fasciitis (CNF). We developed a rat model of CNF, mimicking as closely as possible the human-CNF, to study the effect of a NSAIDs, diclofenac, as a promoting factor. Twenty rats were injected bilaterally in the neck with peptostreptococcus and with a fresh saliva specimen for another 20 rats. Half of each group was given an intramuscular injection of 4 mg/kg diclofenac at the time of inoculation and 24 h later, and the other half saline injections; rats were killed at day 7 and clinical, bacterial and histological studies were performed to assess the infectious process and the incidence of CNF. No statistically significant difference was found between groups treated with diclofenac vs. the saline injection groups. However a significant correlation was noted between clinical observation, bacterial density and histological signs of inflammation. CNF has a high mortality rate and the use of NSAIDs in conditions potentially leading to CNF is very common. However, our rat model does not support the hypothesis of a promoting role of diclofenac which was occasionally suggested in the medical literature. This study suggests that diclofenac does not seem to increase the risk of occurrence of CNF. Nonetheless, NSAIDs can mask inflammatory signs of an already spreading CNF.     

Does personal initiative training work as a stress management intervention?

An experimental trial is reported that compares 2 stress management intervention programs and a waitlist control. Both programs involved training in problem-focused strategies of identifying and changing the sources of stress. One of the programs contained additional content on how to display more personal initiative (PI). Both programs involved 2 sessions held 1 week apart, each session lasting 3-4 hr. Strain was measured before training and at 7 and 13 weeks after the initial session. Results show that both programs were effective at reducing strain, whereas the waitlist group showed no change in strain. The PI program increased proactive behavior at 7 weeks as determined by independent evaluations, although the same pattern was not observed for PI self-reports. Proactive behavior did not appear to mediate the effects of training programs on strain.