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1.
Jacqueline Nuttall Kerenza Hood Theo JM Verheij Paul Little Curt Brugman Robert ER Veen Herman Goossens Christopher C Butler 《BMC family practice》2011,12(1):1-10
Background
Primary care providers play an important role in preventing and managing cardiovascular disease. This study compared the quality of preventive cardiovascular care delivery amongst different primary care models.Methods
This is a secondary analysis of a larger randomized control trial, known as the Improved Delivery of Cardiovascular Care (IDOCC) through Outreach Facilitation. Using baseline data collected through IDOCC, we conducted a cross-sectional study of 82 primary care practices from three delivery models in Eastern Ontario, Canada: 43 fee-for-service, 27 blended-capitation and 12 community health centres with salary-based physicians. Medical chart audits from 4,808 patients with or at high risk of developing cardiovascular disease were used to examine each practice's adherence to ten evidence-based processes of care for diabetes, chronic kidney disease, dyslipidemia, hypertension, weight management, and smoking cessation care. Generalized estimating equation models adjusting for age, sex, rurality, number of cardiovascular-related comorbidities, and year of data collection were used to compare guideline adherence amongst the three models.Results
The percentage of patients with diabetes that received two hemoglobin A1c tests during the study year was significantly higher in community health centres (69%) than in fee-for-service (45%) practices (Adjusted Odds Ratio (AOR) = 2.4 [95% CI 1.4-4.2], p = 0.001). Blended capitation practices had a significantly higher percentage of patients who had their waistlines monitored than in fee-for-service practices (19% vs. 5%, AOR = 3.7 [1.8-7.8], p = 0.0006), and who were recommended a smoking cessation drug when compared to community health centres (33% vs. 16%, AOR = 2.4 [1.3-4.6], p = 0.007). Overall, quality of diabetes care was higher in community health centres, while smoking cessation care and weight management was higher in the blended-capitation models. Fee-for-service practices had the greatest gaps in care, most noticeably in diabetes care and weight management.Conclusions
This study adds to the evidence suggesting that primary care delivery model impacts quality of care. These findings support current Ontario reforms to move away from the traditional fee-for-service practice.Trial Registration
ClinicalTrials.gov: NCT00574808 相似文献2.
Purpose
This study explored the residents’ health outcomes of long‐term care (LTC) facilities and examined the risk factors in individual and institutional levels during 1 year of admission.Methods
The study included four stages of interviews with residents in 31 nursing homes and 64 residential care homes. Three hundred and twenty-five residents at baseline were interviewed, and 206 completed the interviews at follow‐up. Five outcomes including residents’ physical/mental functional status and subjective health status in Short Form‐36 were analyzed using latent growth curve models (LGCMs).Results
Only the physical component summary (PCS) had increased significantly. The most influential risk factors to outcomes were the intra‐individual-level time‐varying variables, including self‐rated health and with/without tubing care. Some predictive inter‐individual-level factors were also found. For institutional characteristics, small‐sized homes (<49 beds) with low occupancy rates showed a lower growth rate in residents’ mental component summary (MCS) and PCS over 1 year and private sector homes showed the most significant growth rates in MCS.Conclusions
The methodological strength using LGCMs provides a framework for systematically assessing the influence of risk factors from various levels on residents’ outcomes and follow‐up change. It is evident that factors in various levels all influenced residents’ outcomes which support critical information for case mix and quality management in LTC facilities. Under the scenario of a surplus of institutional care in Taiwan, we suggest that institutions must focus more on residents’ psychological well‐being and care quality, especially in small‐sized homes in relation to the outcomes of its residents. 相似文献3.
Prof. Dr. H. Stummer E. N?hammer G. Brauchle C. Schusterschitz 《Pr?vention und Gesundheitsf?rderung》2011,6(1):75-80
Background
The present paper describes and analyzes the current status of workplace health promotion programs in Austria.Methods
The current status was analyzed using a quantitative survey.Results
In Austria, most organizations have implemented behavioural and team-oriented interventions. However, participative programs and systematic evaluations are found less frequently than expected.Conclusion
It seems necessary to focus on two critical success factors for health projects in Austria: increase the participation of employees and use systematic project management with closed learning cycles. 相似文献4.
Jonathan Ives Sheila Greenfield Jayne M Parry Heather Draper Christine Gratus Judith I Petts Tom Sorell Sue Wilson 《BMC public health》2009,9(1):1-13
Background
There have been many randomized controlled trials of screening and brief alcohol intervention in primary care. Most trials have reported positive effects of brief intervention, in terms of reduced alcohol consumption in excessive drinkers. Despite this considerable evidence-base, key questions remain unanswered including: the applicability of the evidence to routine practice; the most efficient strategy for screening patients; and the required intensity of brief intervention in primary care. This pragmatic factorial trial, with cluster randomization of practices, will evaluate the effectiveness and cost-effectiveness of different models of screening to identify hazardous and harmful drinkers in primary care and different intensities of brief intervention to reduce excessive drinking in primary care patients.Methods and design
GPs and nurses from 24 practices across the North East (n = 12), London and South East (n = 12) of England will be recruited. Practices will be randomly allocated to one of three intervention conditions: a leaflet-only control group (n = 8); brief structured advice (n = 8); and brief lifestyle counselling (n = 8). To test the relative effectiveness of different screening methods all practices will also be randomised to either a universal or targeted screening approach and to use either a modified single item (M-SASQ) or FAST screening tool. Screening randomisation will incorporate stratification by geographical area and intervention condition. During the intervention stage of the trial, practices in each of the three arms will recruit at least 31 hazardous or harmful drinkers who will receive a short baseline assessment followed by brief intervention. Thus there will be a minimum of 744 patients recruited into the trial.Discussion
The trial will evaluate the impact of screening and brief alcohol intervention in routine practice; thus its findings will be highly relevant to clinicians working in primary care in the UK. There will be an intention to treat analysis of study outcomes at 6 and 12 months after intervention. Analyses will include patient measures (screening result, weekly alcohol consumption, alcohol-related problems, public service use and quality of life) and implementation measures from practice staff (the acceptability and feasibility of different models of brief intervention.) We will also examine organisational factors associated with successful implementation.Trial registration
Current Controlled Trials ISRCTN06145674. 相似文献5.
Purpose
To examine the effects of a multi-factorial, intensified treatment on self-reported health status, treatment satisfaction, and diabetes-related distress in screen-detected type 2 diabetes patients.Methods
Cluster-randomised controlled trial; A total of 498 screen-detected type 2 diabetes patients from 79 general practices were assigned to intensified (n = 255) or routine treatment according to Dutch guidelines (n = 243). At baseline and after 3 years, patients completed the Short Form-36 and the European Quality of Life-5 Dimensions questionnaires. After 4.5 years, patients completed the Diabetes Treatment Satisfaction Questionnaire and the Problem Areas In Diabetes scale. We analysed the effects of intensified treatment on self-rated health status, treatment satisfaction, and diabetes-related distress, using random effects models to account for clustering at practice level.Results
Three to 5 years after type 2 diabetes was detected by screening, there were no differences between intensified and routine treatment in self-reported health status, treatment satisfaction, and diabetes-related distress.Conclusions
Multi-factorial, intensified treatment did not influence self-rated health status, treatment satisfaction, and distress in screen-detected type 2 diabetes patients. Therefore, health care professionals do not have to fear negative effects of an intensified treatment on these psychological outcomes. 相似文献6.
Purpose
The inclusion of patient-reported outcome measures (PROMs) in the routine clinical care of chronically ill patients has the potential to add valuable information about the impact of the disease and its treatment and promotes effective patient self-management in which patients become more active participants in their own care. PROMs provide clinicians with timely information on patients’ symptoms as well as functional and emotional status. PROMs are a useful tool for enhancing patient–clinician communication.Methods
We develop a conceptual framework describing the potential effects of the use of PROMs in chronic care management. The framework summarizes insights from the methods for evaluating the clinical effectiveness and methods for the health technology assessment of diagnostic technologies and results from the relevant studies.Results
The framework describes potential effects, from proximal to distal, including communication (patient–clinician, patient–relative, clinician–clinician, and clinician–relative), engaging patients in shared clinical decision making, patient management (clinician management and patient self-management), and patient outcomes. Important potential effects also include enhancement in patient activation as well as improvements in clinician and patient satisfaction, and patient adherence to recommended treatment. Previous frameworks have described patient–physician communication, patient satisfaction, and health outcomes. Our framework adds unique domains, including patient engagement, patient activation, shared clinical decision making, and patient self-management.Conclusions
The framework can be used as a tool to guide the development of interventions to improve chronic care management through the use of PROMs. 相似文献7.
Objectives
The review aimed to assess the effectiveness of conditional cash transfers (CCTs) in improving child health in low- and middle-income countries.Methods
Seven electronic databases were searched for papers: MEDLINE, EMBASE, PubMed, PsychINFO, BIOSIS Previews, Academic Search Complete, and CSA Sociological Abstracts. The included studies comprised of randomised controlled trials and controlled before-and-after studies evaluating the impact of CCTs on child health. Due to the substantial heterogeneity of the studies, a narrative synthesis was conducted on the extracted data.Results
Sixteen studies predominantly from Latin American countries met the inclusion criteria. The outcomes reported by the studies in relation to CCTs’ effectiveness in improving child health were reduction in morbidity risk, improvement in nutritional outcomes, health services utilisation, and immunisation coverage.Conclusions
The review suggests that to a large extent, CCTs are effective in improving child health by addressing child health determinants such as access to health care, child and maternal nutrition, morbidity risk, immunisation coverage, and household poverty in developing countries particularly middle-income countries. Of importance to both policy and practice, it appears that CCTs require effective functioning of health care systems to effectively promote child health. 相似文献8.
9.
Background
Guidelines aim to improve the quality of health care by providing scientific knowledge for physicians and patients regarding specific options for everyday healthcare practice. Their purpose is to describe current knowledge, based on scientific evidence and practice experience for specific problems of health care; to evaluate methodological and clinical aspects; to clarify conflicting points of view; and to weigh benefits and risks in order to make recommendations for the optimum procedures and actions.Methods
The question was raised on how to update the stage 3 guideline for early detection of breast cancer in Germany in view of the difficulties of this complex chain of health care, the high methodological requirements, and the limited time and finances for the development of guidelines. It was assumed that, besides incorporating advances in scientific knowledge, such updating requires a check of the present applications of the guideline in clinical practice, including its dissemination, implementation, and consequences on healthcare services and outcomes.Results
The concept of quality management for the stage 3 guideline of the Association of the Scientific Medical Societies in Germany (AWMF) was expanded for continous updating under systematically defined conditions.Conclusions
The stepwise concept proved to be practical. The update was realized successfully with clearly lower expenditures compared with development of the first guideline for early detection of breast cancer in Germany. 相似文献10.
Objective
This article deals with the question of what prevents people from living healthy and devoting themselves to health care and which scientific theoretical models form the basis for the avoidance of health care and prevention.Methods
After a literature search in the German-speaking literature with a focus on Austrian habitations, data were compared and summarized.Results
Individual resistance play a major role as to why people avoid health care and scientific theoretical criticism on prevention and health care supports these attitudes. 相似文献11.
Background
It has been proposed that greater availability of primary medical care practitioners (GPs) contributes to better population health. We evaluated whether measures of the supply and structure of primary medical services are associated with health and health care indicators after adjusting for confounding.Methods
Data for the supply and structure of primary medical services and the characteristics of registered patients were analysed for 99 health authorities in England in 1999. Health and health care indicators as dependent variables included standardised mortality ratios (SMR), standardised hospital admission rates, and conceptions under the age of 18 years. Linear regression analyses were adjusted for Townsend score, proportion of ethnic minorities and proportion of social class IV/ V.Results
Higher proportions of registered rural patients and patients ≥ 75 years were associated with lower Townsend deprivation scores, with larger partnership sizes and with better health outcomes. A unit increase in partnership size was associated with a 4.2 (95% confidence interval 1.7 to 6.7) unit decrease in SMR for all-cause mortality at 15–64 years (P = 0.001). A 10% increase in single-handed practices was associated with a 1.5 (0.2 to 2.9) unit increase in SMR (P = 0.027). After additional adjustment for percent of rural and elderly patients, partnership size and proportion of single-handed practices, GP supply was not associated with SMR (-2.8, -6.9 to 1.3, P = 0.183).Conclusions
After adjusting for confounding with health needs of populations, mortality is weakly associated with the degree of organisation of practices as represented by the partnership size but not with the supply of GPs. 相似文献12.
Background
From 2004 to 2009 there was almost a 12% rise in emergency admissions in England. This can be explained partly by an aging population and other socio-demographic characteristics, but much cannot be explained by these factors. We explored aspects of care, in addition to known demographic characteristics in general practice, that are associated with emergency admissions.Methods
A cross-sectional design employing hospital admission data from 76 general practices in Northamptonshire, England for 2006–08, including demographic data, quality and outcomes framework points and GP patient survey outcomes.Results
There were statistically significant associations between emergency admissions and age, gender, distance from hospital and proportion classified as white. There was also a statistically significant relationship between emergency admissions and being able to book an appointment with a preferred doctor; this relationship was stronger in less deprived communities.Conclusions
Enabling patients to book with a preferred doctor, particularly those in less deprived communities could have an impact on reducing emergency admissions. It is possible that being able to consult a preferred GP gives patient’s confidence to avoid an emergency admission or it facilitates consistent clinical management that helps prevent the need for admission. However the findings only explained some of the variation. 相似文献13.
Eric J. Belasco Gordon Gong Barbara Pence Ethan Wilkes 《Applied health economics and health policy》2014,12(4):461-470
Background
This research seeks to identify the relationship between economic factors related to the ability to receive and pay for health services and adverse cancer outcomes, as well as preventative screening and behavioral factors that influence the risk of cancer. We focus on the Northern High Plains region, where we are able to compare regions with extremely low access to health services with those with relatively high levels of access.Objective
This study aims to identify health disparities in rural communities, particularly among Native American populations, and, thereby, begin to determine the most effective means by which to deliver health services to areas where geography, economics, and culture might prevent traditional models of health delivery from providing sufficient incentives for the prevention of adverse cancer-related outcomes.Methods
The Health Care Accessibility Index (HCAI) is computed through the use of principal component analysis and includes economic variables as well as variables concerning institutional and geographic access to health care. Index values are then regressed onto cancer outcomes, cancer-prevention outcomes, and cancer-related risk, using weighted least squares and quantile regressions.Results
Counties with relatively poor access to health care (low HCAI) also have statistically (1) lower breast cancer screening rates, (2) higher smoking prevalence, (3) higher obesity prevalence, and (4) higher cancer-related mortality rates. Breast cancer screening is found to be especially sensitive to areas of low health accessibility.Conclusions
Empirical results provide support for policy efforts to increase the accessibility of health care services that are targeted to areas with low mammography screening rates, high obesity rates, high smoking prevalence, as well as areas near Native American reservation territories. 相似文献14.
Dr. publ. health U. Franken 《Pr?vention und Gesundheitsf?rderung》2009,4(1):23-34
Background
Leading health scientists agree that the emotions play the central role in a comprehensive bio-psycho-social theory of health and disease.Aim
The article wants to show how health-related findings from natural and human sciences contribute qua the focus on emotion to a cross-lane model and thus term confusion and overlaps can be avoided.Results and conclusions
Such an approach not only fertilizes the genesis of theory in the health sciences, it will also help to form a basis for practical interventions in prevention and health promotion. It provides an integrative perspective instead of the prevention of a variety of risks and diseases; genuine, and broadly effective salutogenesis instead of the widespread focus on risk factors; suitability for the prevention of hitherto neglected mental disorders, etc. 相似文献15.
16.
Aim
To transform knowledge from public health and health services research into actual improvement of services is highly relevant for spending public research resources effectively. Fostering stakeholder interaction throughout the entire research process is one potential avenue towards this aim. The objective of this paper is to look for established practices with the aim to promote the usability of research in policy and practice through interaction.Subject and methods
We conducted 11 semi-structured telephone-interviews with senior experts from the same number of public health and health services research institutions in the Netherlands, the United Kingdom and Norway.Results
Practice patterns are manifold, but three key domains were identified:- Research implementation is explicitly part of the organisation’s mission. Research commissioning institutions serve as intermediaries between research, policy and practice.
- Funds are earmarked for implementation activities. In regular evaluation cycles special consideration is given to the impact of research.
- Multiple forums for interaction support the ability of researchers to actively communicate with stakeholders. Network-building skills are developed alongside scientific competence.
Conclusion
Promising initiatives can be found in practice. Further research is needed into what difference it makes how the exchange between research and policy is organised. 相似文献17.
Perman G Rossi E Waisman GD Agüero C González CD Pallordet CL Figar S González Bernaldo de Quirós F Canning J Soriano ER 《Cost effectiveness and resource allocation : C/E》2011,9(1):4-11
Background
Mounting evidence shows that multi-intervention programmes for hypertension treatment are more effective than an isolated pharmacological strategy. Full economic evaluations of hypertension management programmes are scarce and contain methodological limitations. The aim of the study was to evaluate if a hypertension management programme for elderly patients is cost-effective compared to usual care from the perspective of a third-party payer.Methods
We built a cost-effectiveness model using published evidence of effectiveness of a comprehensive hypertension programme vs. usual care for patients 65 years or older at a community hospital in Buenos Aires, Argentina. We explored incremental cost-effectiveness between groups. The model used a life-time framework adopting a third-party payer's perspective. Incremental cost-effectiveness ratio (ICER) was calculated in International Dollars per life-year gained. We performed a probabilistic sensitivity analysis (PSA) to explore variable uncertainty.Results
The ICER for the base-case of the "Hypertension Programme" versus the "Usual care" approach was 1,124 International Dollars per life-year gained. PSA did not significantly influence results. The programme had a probability of 43% of being dominant (more effective and less costly) and, overall, 95% chance of being cost-effective.Discussion
Results showed that "Hypertension Programme" had high probabilities of being cost-effective under a wide range of scenarios. This is the first sound cost-effectiveness study to assess a comprehensive hypertension programme versus usual care. This study measures hard outcomes and explores robustness through a probabilistic sensitivity analysis.Conclusions
The comprehensive hypertension programme had high probabilities of being cost-effective versus usual care. This study supports the idea that similar programmes could be the preferred strategy in countries and within health care systems where hypertension treatment for elderly patients is a standard practice. 相似文献18.
Guill&#;n-Sol&#; Mireia Soler Mieras Aina Tom&#;s-Vidal Ant&#;nia M 《BMC family practice》2013,14(1):1-8
Background
Inappropriate use of antidepressants (AD), defined as either continuation in the absence of a proper indication or continuation despite the lack of therapeutic efficacy, applies to approximately half of all long term AD users.Methods/design
We have designed a cluster randomized controlled clinical trial to assess the (cost-) effectiveness of an antidepressant cessation advice in the absence of a proper indication for maintenance treatment with antidepressants in primary care. We will select all patients using antidepressants for over 9 months from 45 general practices. Patients will be diagnosed using the Composite International Diagnostic Interview (CIDI) version 3.0, extended with questions about the psychiatric history and previous treatment strategies. General practices will be randomized to either the intervention or the control group. In case of overtreatment, defined as the absence of a proper indication according to current guidelines, a cessation advice is given to the general practitioner. In the control groups no specific information is given. The primary outcome measure will be the proportion of patients that successfully discontinue their antidepressants at one-year follow-up. Secondary outcomes are dimensional measures of psychopathology and costs.Discussion
This study protocol provides a detailed overview of the design of the trial. Study results will be of importance for refining current guidelines. If the intervention is effective it can be used in managed care programs.Trial registration
NTR2032 相似文献19.
Background
The rhetoric of primary health care philosophy in the district health system is widely cited as a fundamental component of the health transformation process in post-apartheid South Africa. Despite South Africa??s progress and attempts at implementing primary health care, various factors still limit its success.Discussion
Inconsistencies and poor understanding of primary care and primary health care raises unrealistic expectations in service delivery and health outcomes, and blame is apportioned when expectations are not met. It is important for all health practitioners to consider the contextual influences on health and ill-health and to recognise the role of the underlying determinants of ill-health, namely, social, economic and environmental influences. The primary health care approach provides a strong framework for this delivery but it is not widely applied. There is a need for renewed political and policy commitments toward quality primary health care delivery, re-orientation of health care workers, integration of primary health care activities into other community-based development, improved management skills and effective coordination at all levels of the health system. There should also be optimal capacity building, and skills development in problem-solving, communication, networking and community participation.Summary
A well-functioning district health system is required for the re-engineering of primary health care. This strategy requires a strong leadership, a strengthening of the current district heath system and a greater emphasis on health promotion, prevention, and community participation and empowerment. 相似文献20.
D. M. Crone E. E. O’Connell P. J Tyson F. Clark-Stone S. Opher D. V. B. James 《Zeitschrift fur Gesundheitswissenschaften》2012,20(5):519-524