Evidence-based practice in primary care: past, present and future

As in other health care specialities, evidence-based practice is beginning to have an impact on the philosophy and workings of primary care. Some practising clinicians, however, may wish to question its relevance to their everyday work, and whether general practitioners and other members of the primary health care team can realistically adopt a new approach to clinical decision making, at a time of such high workload and competing priorities.
Major changes have taken place during the last 20 years as a result of the National Health Service (NHS) reforms, the development of general practice and primary care research, and other health service innovations such as the introduction of new technologies, which have had an important impact on primary care. Issues such as the availability and use of different research methods, the role of experts, and the development of guidelines, audit and evaluation of care, are becoming subject to renewed scrutiny.
Within this context, this article explores the potential of an evidence-based approach in the primary care setting, and discusses possible strategies for change to assist the dissemination of research into practice and the implementation of evidence-based health care.     

Teamwork in primary care mental health: a policy analysis

Aim This paper reports a policy analysis conducted to examine the potential impact of recent mental health policy on team working in Primary Care Mental Health in England. Method An analysis of relevant policy documents was conducted. From an original selection of 49 documents, 15, which had significant implications for Primary Care Mental Health Teams, were analysed thematically. Findings There were no clear guidelines or objectives for Primary Care Mental Health Teams evident from the policy analysis. Collaborative working was advocated, yet other elements in the policies were likely to prevent this occurring. There was a lack of clarity concerning the role and function of new professions within Primary Care Mental Health Teams, adding further uncertainty to an already confused situation. Conclusion This uncertainty has the potential to reinforce professional barriers and increase the current difficulties with team working. Implications to nursing managers An analysis of recent policy contributes to our understanding of the context of care. The lack of clarity in current health policy presents a significant challenge for those managing primary care mental health teams. Team working is likely to improve if targets, processes and responsibilities are made clearer.     

Quality of primary nursing care for Bedouin in Jordan

This paper presents a critique of the use of the Maximizing Access to Quality (MAQ) instrument supplemented by non-participant observation as a way of assessing the quality of nursing care in primary care clinics in the north-eastern Badia of Jordan, where populated by Bedouin. The MAQ checklist with non-participant observation of clinic care was used to assess the quality of care in four comprehensive health centres. In the four comprehensive health centres, more than half of the indicators for measuring the quality of the physical conditions were adequate. In relation to personnel, general practitioners were available, but in-service training was needed and no social workers were available. Provision of health services was optimal in three of the clinics but was less than optimal in the remotest clinic. Health education was done sporadically and continuity of care was the main challenge in provision in the four clinics. The MAQ checklist for assessing the quality of health provision in maternal and child health and reproductive services is a useful instrument to capture a snapshot of health-care provision; however, it is not suited to a rural setting.     

Meaning and measurement: an inclusive model of evidence in health care

Evidence-based approaches are assuming prominence in many health-care fields. The core ideas of evidence-based health care derive from clinical epidemiology and general internal medicine. The concept of evidence has yet to be analysed systematically; what counts as evidence may vary across disciplines. Furthermore, the contribution of the social sciences, particularly qualitative methodology, has received scant attention. This paper outlines a model of evidence that describes four distinct but related types of evidence: qualitative-personal; qualitative-general; quantitative-general and quantitative-personal. The rationale for these distinctions and the implications of these for a theory of evidence are discussed.     

Mental health policy and integrated care: global perspectives

Although omitted from the World Health Organization's eight Millennium Development Goals, mental illness ranks fourth of the 10 leading causes of disability in the world and is expected to approach second place by 2020. Scarce resources challenge responses to mental health needs. Effective approaches must consider existing healthcare delivery networks, nurses as care providers, as well as social, cultural, political and historical contexts. This paper reviews policy development and care approaches to address mental health needs around the world. Challenges, successes and further needs are discussed. Selected articles were reviewed to represent varied approaches to address mental health needs in countries with diverse resources and infrastructures. Integrated systems offer one model for addressing mental health needs along with physical health needs within a population. While potentially an efficient strategy, caution is advised to ensure services are integrated and not merely added on top of an already overburdened system. As the largest group of healthcare professionals worldwide, nurses play a key role in the delivery of mental health services. Nurses have an opportunity, if not a responsibility, to collaborate across borders sharing education and innovative approaches to care delivery.     

Quality of chronic kidney disease management in primary care: a retrospective study

Background: Early detection and appropriate management of chronic kidney disease (CKD) in primary care are essential to reduce morbidity and mortality. Aim: To assess the quality of care (QoC) of CKD in primary healthcare in relation to patient and practice characteristics in order to tailor improvement strategies. Design and setting: Retrospective study using data between 2008 and 2011 from 47 general practices (207 469 patients of whom 162 562 were adults). Method: CKD management of patients under the care of their general practitioner (GP) was qualified using indicators derived from the Dutch interdisciplinary CKD guideline for primary care and nephrology and included (1) monitoring of renal function, albuminuria, blood pressure, and glucose, (2) monitoring of metabolic parameters, and alongside the guideline: (3) recognition of CKD. The outcome indicator was (4) achieving blood pressure targets. Multilevel logistic regression analysis was applied to identify associated patient and practice characteristics. Results: Kidney function or albuminuria data were available for 59 728 adult patients; 9288 patients had CKD, of whom 8794 were under GP care. Monitoring of disease progression was complete in 42% of CKD patients, monitoring of metabolic parameters in 2%, and blood pressure target was reached in 43.1%. GPs documented CKD in 31.4% of CKD patients. High QoC was strongly associated with diabetes, and to a lesser extent with hypertension and male sex. Conclusion: Room for improvement was found in all aspects of CKD management. As QoC was higher in patients who received structured diabetes care, future CKD care may profit from more structured primary care management, e.g. according to the chronic care model.

• Key points

• Quality of care for chronic kidney disease patients in primary care can be improved.

• In comparison with guideline advice, adequate monitoring of disease progression was observed in 42%, of metabolic parameters in 2%, correct recognition of impaired renal function in 31%, and reaching blood pressure targets in 43% of chronic kidney disease patients.

• Quality of care was higher in patients with diabetes.

• Chronic kidney disease management may be improved by developing strategies similar to diabetes care.

     

Evidence-based practice and health visiting: the need for theoretical underpinnings for evaluation

In this paper we argue that evidence-based practice, which is being introduced throughout the British National Health Service to make decisions about the allocation of limited resources, provides a welcome opportunity for health visitors to demonstrate their efficacy, skills and professionalism. However, the paper argues that to view health visiting as evidence-based is not to reduce health visiting merely to a technology through which scientific solutions are applied to social problems. Rather, health visiting needs to be viewed as a political movement, based on a particular model of society, which shapes the goals which health visitors pursue and influences the strategies they adopt to achieve their goals. The paper describes various models of health visiting as a way of showing how the goals of health visiting are always framed within a particular set of assumptions and causal explanations. The paper then turns to look at the issue of evaluating health visiting services. It is argued that evaluation should properly take account of the models which shape health visitors' goals and intervention strategies, and in turn, health visitors need to be explicit about the theoretical frameworks underpinning their interventions. Finally, it is argued that health visitors' knowledge and understanding of a range of models of society enables them to move between the various models to choose the most appropriate and effective means of intervention. Hence it is concluded that the emphasis on evidence-based practice provides health visitors with a valuable opportunity to show that their unique, professional skills and understanding are the preconditions for effective intervention.     

Evidence into practice: a theory based study of achieving national health targets in primary care

RATIONALE, AIMS AND OBJECTIVES: This study investigates reasons why general practices achieve nationally set milestones to different extents. It compares the beliefs, self-reported behaviours and organizational context of general practitioners (GPs) who have been successful in achieving milestones set out in the UK's National Service Framework (NSF) for Coronary Heart Disease (CHD) with those who have been less successful. METHODS: Sixteen London GPs were interviewed, eight 'high implementers' (having met five or more of six CHD NSF milestones) and eight 'low implementers' (having met one or two milestones). Practices were matched for practice size across the groups as far as possible. The interview consisted of open-ended questions, based on theoretical constructs identified as key to implementation research in a previous project. Interviews were transcribed and analysed with Interpretative Phenomenological Analysis (IPA). RESULTS: There were three main areas that differentiated high and low implementers: beliefs about evidence-based practice, control over professional practice and consequences of achieving the milestones. Low implementers: (i) expressed less belief in evidence-based guidelines as the basis of their practice; (ii) were more concerned about their lack of control over the development and implementation of the guidelines (lack of ownership), and over their own practice (lack of autonomy); and (iii) perceived more negative consequences and fewer positive consequences, both for themselves and for patient care. CONCLUSIONS: This study demonstrates the application of psychological theory in trying to understand and improve professional practice. The results suggest areas that could be targeted in developing interventions to increase guideline implementation in primary care.     

Effects of an implemented care policy on patient and personnel experiences of care

Effects of an implemented care policy on patient and personnel experiences of care A care policy was implemented within health care in the county of Västerbotten, Sweden. A questionnaire was administered before and after the implementation of the care policy to assess its effects. Patients within hospital care and primary health care described their experiences in a base‐line study (n=3950) in 1994 and a follow‐up study (n=2941) in 1996. On the same occasions personnel (n=2362 and 2310, respectively) answered the same questionnaire assessing what they thought their patients experienced. No significant positive effects of the implementation were seen by the patients. Fewer patients felt that they were understood when they talked about their problems, dared to express criticism or denied they were treated nonchalantly in the follow‐up study. The experiences of the personnel were in line with those of the patients concerning nonchalant treatment in the follow‐up study. Furthermore, fewer staff members thought that their patients felt they had adequate help with hygiene whilst more thought that their patients felt they were responded to in a loving way. One interpretation of the negative outcome is that organizational changes, strained resources and cuts in staffing during the 90s may have reduced the possibility of integrating the care policy in spite of an ambitious and extensive intervention.     

Nurses and English primary care groups: their experiences and perceived influence on policy development

AIMS OF THE STUDY: To investigate the experiences and perceived influence of nurses serving on English primary care group boards. BACKGROUND: The development of the nursing workforce and nursing services in primary care have been piecemeal and nurses have not always contributed to policy development. The recent establishment of primary care groups (PCGs) in the United Kingdom (UK) potentially offers nurses the opportunity to take a concerted and strategic role in developing professional roles and planning service developments. RESEARCH METHODS: As part of a longitudinal study of a 15% random sample of English primary care groups, nurse board members were surveyed in the winter of 1999. One hundred and forty-four nurses were invited to return self-completion questionnaires. RESULTS: Completed questionnaires were returned by 106 of those invited to participate (73%). Respondents reported that combining their usual work with their role in the PCG was frequently difficult. Only 26% perceived that they had been well prepared for their new role. Compared with other board members [for example, general practitioners (GPs)], nurses perceived that their own influence was limited, with only a quarter rating the influence of nurses on decision-making as great. Most of the sample were feeding back information to other primary care and community nurses working in the locality and 52% rated communication with this wider constituency as good or better. Nurse board members were enthusiastic about their role and optimistic about the positive future impact of PCGs on health. CONCLUSIONS: PCGs are still at a relatively early stage in their development. It is still too early to assess their impact on nurses working in primary care and community settings. Board membership offers nurses a voice in local health policy development.     

Marital status, feeling depressed and self-rated health in rural female primary care patients

Objective To determine whether marital status and self‐assessed mental health are independent risk factors for poor self‐rated overall health among female primary care patients. Design We conducted a cross‐sectional survey of family medicine patients treated in a clinic in rural Minnesota. Complete responses were obtained from 723 women. Self‐ratings of mental health, demographics and symptoms were used to predict self‐rated overall health. Results Women who were single, divorced or otherwise not married, or widowed had lower odds of good self‐rated overall health (OR = 0.39, P = 0.004) compared with married women. Women who were 65 years of age and over (OR = 0.31, P = 0.017), women who rated themselves as depressed (OR = 0.54, P = 0.029), and women who reported more physical symptoms (OR = 0.78, P = 0.000) also were less likely to have good health, compared with younger women, women who did not feel depressed, and women with fewer physical symptoms, respectively. Education was not independently related to health in this sample. Worry was related to health in the univariate analysis but not after controlling for self‐assessed depression. Conclusions In order to improve overall health among rural women seen in primary care settings, special attention may need to be directed at women who are single, are older, report more physical symptoms, and feel depressed. Programmes should include self‐help materials, support groups and counselling services addressing social isolation, employment and financial hardship.     

Evaluating the impact of an evidence-based medicine educational intervention on primary care doctors' attitudes, knowledge and clinical behaviour: a controlled trial and before and after study

RATIONALE, AIMS AND OBJECTIVES: Traditional continuing medical education programmes that offer passive learning have been shown to be poorly effective at changing doctors' clinical behaviour. A multifaceted evidence-based medicine (EBM) intervention was conducted at the largest health maintenance organization (HMO) in Israel, attempting to facilitate a change in doctors' attitudes, knowledge and clinical behaviour. No study thus far has examined the association between the teaching of EBM principles and doctors' clinical behaviour. This study evaluated the intervention programme through a controlled trial and before and after study. The objective of the evaluation is binary: first, to examine the impact of an educational intervention on family doctors' test ordering performance and drug utilization by their patients; and second, to assess the impact of the intervention on attitudes towards evidence-based practice and knowledge. METHODS: Controlled trial and before and after study. Primary care clinics comprising similar patient characteristics were randomly allocated to the experimental or to the control group. Doctors in the experimental group participated in an EBM educational intervention, while the control group did not take part in the intervention. Clinicians' test ordering performance and their patients' drug utilization were derived from the HMO's database before intervention, after workshops and after intervention. Participants in the controlled trial consisted of 75 doctors and their 106 349 patients. The before and after study evaluated intervention doctors' (n = 70) EBM attitudes and knowledge through a validated questionnaire before and after workshops. RESULTS: EBM workshops enhanced intervention doctors' EBM knowledge scores from 22.4/100 before workshops to 40.8/100 after workshops (P = 0.000). Doctors improved their ability to formulate clinical questions while enhancing their search strategy using Medline. In a linear regression model, two covariates, specialization (B = 12.59; P = 0.001) and habitually reading medical journals (B = 6.45; P = 0.052), best explained the variance in doctors' EBM knowledge scores, while controlling for pre-intervention scores (R(2) = 0.569; P = 0.000). Results from the controlled trial indicated that no statistically significant differences were found between intervention and control doctors' test ordering performances, and their patients' drug utilization. CONCLUSIONS: The results of the study suggest that the intervention positively influenced attitudes and knowledge; however, no statistically significant impact was found on doctors' test ordering performance and on their patients' drug utilization. The intervention's inability to change doctors' clinical behaviour might be remedied by improving future interventions through adding additional facets to the educational intervention, such as social marketing techniques and personal feedback. A longer and more extensive intervention might be more effective but is extremely difficult to execute as we found in this study. Future larger-scale interventions must incorporate the intervention into the routines of the organization, thus minimizing barriers towards EBM implementation.     

Asthma nurse practice improves outcomes and reduces costs in primary health care

OBJECTIVE: The aim of this study was to elucidate the care of patients with asthma in primary health care from medical, patient self-management, health, quality of life, and health economic perspectives. METHODS: Asthma nurse practice (ANP), an alternative asthma self-management strategy, was compared with traditional asthma care in primary health care in southern Sweden regarding medical history, lifestyle, self-management, symptoms caused by asthma, effects on sick leave, state of health, quality of life and health care costs. The first part of the investigation comprised a retrospective study of a randomly selected sample of patient records of asthmatics (n=152). The second part, lasting 3 months, was prospective and included consecutive patients visits (n=347). RESULTS: The ANP approach showed better results in most of the evaluated outcomes such as asthma quality documentation and self-management and the number of asthma symptoms was significantly lower. From a health economic perspective the results were encouraging with respect to ANP. CONCLUSION: This alternative asthma strategy, ANP, improved asthma care in primary health care and resulted in economic advantages in the health care sector. However the result may only be generalized to other practices working with asthma nurses in the same way.     

Continuing care: developing a policy analysis for nursing

Many authors have commented on the invisibility of nursing in policy development, implementation and analysis. Some of this invisibility may be attributed to the lack of an easily accessible framework to assist analysis of policy from a nursing perspective. In this paper we offer a framework for nursing policy analysis based on the domain concepts of nursing. We use continuing care for older people, a topical policy issue and fundamental nursing speciality, as a case study to demonstrate the utility and potential of such a framework in action. The resulting analysis helps identify areas of potential policy interest to nurses, raises questions for further policy analysis and offers a coherent position statement for action.     

Quality in health care and ethical principles

Quality in health care and ethical principles The last three decades have seen rapid changes in the way United States of America (USA) health care has been delivered, financed and regulated. Four major stakeholders have emerged in the health care debate: patients, providers, payers and public regulatory agencies. These groups do not agree on a definition of quality health care. This paper suggests five ethical principles - autonomy, justice, beneficence, non-maleficence, and prudence - be included in the framework of quality health care. A framework that outlines possible relationships among these ethical attributes and four major stakeholders is presented.